Provider Demographics
NPI:1699503920
Name:STUTZMAN, KYLEE ROSE (COTA/L)
Entity type:Individual
Prefix:MISS
First Name:KYLEE
Middle Name:ROSE
Last Name:STUTZMAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 COACHMANS TRL
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-4910
Mailing Address - Country:US
Mailing Address - Phone:574-206-6619
Mailing Address - Fax:
Practice Address - Street 1:1903 COACHMANS TRL
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-4910
Practice Address - Country:US
Practice Address - Phone:574-206-6619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003487A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant