Provider Demographics
NPI:1518786623
Name:KETTLESON, KAITLIN HOPE (COTA/L)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:HOPE
Last Name:KETTLESON
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 1:1225 BLAKEWAY ST UNIT 1702
Mailing Address - Street 2:
Mailing Address - City:DANIEL ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29492-8426
Mailing Address - Country:US
Mailing Address - Phone:715-281-8815
Mailing Address - Fax:
Practice Address - Street 1:1169 SHARPESTOWNE CT
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7564
Practice Address - Country:US
Practice Address - Phone:850-341-0418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5717224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant