Provider Demographics
NPI:1912344490
Name:MCCOLLOM, KIMBERLY JOY (COTA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:JOY
Last Name:MCCOLLOM
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:JOY
Other - Last Name:DOANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:5404 PRESTON FALL CITY RD SE
Mailing Address - Street 2:
Mailing Address - City:FALL CITY
Mailing Address - State:WA
Mailing Address - Zip Code:98024-9628
Mailing Address - Country:US
Mailing Address - Phone:425-435-9292
Mailing Address - Fax:
Practice Address - Street 1:5404 PRESTON FALL CITY RD SE
Practice Address - Street 2:
Practice Address - City:FALL CITY
Practice Address - State:WA
Practice Address - Zip Code:98024-9628
Practice Address - Country:US
Practice Address - Phone:425-435-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant