Healthcare Provider Details

I. General information

NPI: 1467813451
Provider Name (Legal Business Name): KENDRA VANDER WAL OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2016
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6970 S HOLLY CIR STE 200
CENTENNIAL CO
80112-1066
US

IV. Provider business mailing address

13863 E LEHIGH AVE APT B
AURORA CO
80014-6134
US

V. Phone/Fax

Practice location:
  • Phone: 720-287-4185
  • Fax:
Mailing address:
  • Phone: 701-400-3879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1464
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: