Provider Demographics
NPI:1487998902
Name:HIERONYMUS, KELLEY ANNE (COTA/L)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:ANNE
Last Name:HIERONYMUS
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 1:2013 LEANNE AVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-2599
Mailing Address - Country:US
Mailing Address - Phone:509-765-3041
Mailing Address - Fax:
Practice Address - Street 1:817 E PLUM ST
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-1870
Practice Address - Country:US
Practice Address - Phone:509-765-7835
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC 00000444224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant