Healthcare Provider Details

I. General information

NPI: 1265637102
Provider Name (Legal Business Name): KRISTY ANN DEETER OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7540 N 19TH AVE
PHOENIX AZ
85021-7967
US

IV. Provider business mailing address

523 MAPLE AVE
TOWER CITY PA
17980
US

V. Phone/Fax

Practice location:
  • Phone: 888-873-4221
  • Fax: 888-543-2289
Mailing address:
  • Phone: 717-647-0427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOC007300L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: