Provider Demographics
NPI:1720798648
Name:MISNER, KIMBERLY (COTA/L)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MISNER
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 1:2575 W PINE MEADOW PL
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84129-1557
Mailing Address - Country:US
Mailing Address - Phone:801-809-1206
Mailing Address - Fax:
Practice Address - Street 1:575 CUTLER DR
Practice Address - Street 2:
Practice Address - City:NORTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84054-2953
Practice Address - Country:US
Practice Address - Phone:801-936-0318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6563197-4202224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant