Basic Information
| Provider Information | |||||||||
| NPI: | 1245689405 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANBORN | ||||||||
| FirstName: | MCKENZIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | KATZMAN | ||||||||
| OtherFirstName: | MCKENZIE | ||||||||
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| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 109 WIND HAVEN DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403568010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 WIND HAVEN DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | NICHOLASVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403568010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592242273 | ||||||||
| FaxNumber: | 8592244675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 168150 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7100413640 | 05 | KY | MEDICAID |