MEDICARE: KRISTEN O'DELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	007397-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007397-1	OTHER	NY	STATE LICENSE

General Provider Information

NPI Number	:	1104364132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN O'DELL

Provider Business Mailing Address
First Line	:	8948 HICKORY MEADOWS RD
Second Line	:
City	:	BOSTON
State	:	NY
Zip	:	14025-9679
Country	:	US
Telephone Number	:	716-226-4365
Fax Number	:

Provider Business Practice Location Address
First Line	:	8948 HICKORY MEADOWS RD
Second Line	:
City	:	BOSTON
State	:	NY
Zip	:	14025-9679
Country	:	US
Telephone Number	:	716-226-4365
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2017
Last Update Date	:	02/10/2017

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Directions to “ KRISTEN O'DELL ” Practice Location

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