Provider Demographics
NPI:1730638669
Name:MARCONETT, KATY
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:
Last Name:MARCONETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W ALEX BELL RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-1246
Mailing Address - Country:US
Mailing Address - Phone:937-681-1239
Mailing Address - Fax:
Practice Address - Street 1:5954 LONGFORD RD
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-2998
Practice Address - Country:US
Practice Address - Phone:937-237-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OT011840225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0406425Medicaid