Healthcare Provider Details

I. General information

NPI: 1902179021
Provider Name (Legal Business Name): KRISTINA SAMPSEL, MOTR/L, S-CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 02/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1849 CALLE LOS VECINOS NW
ALBUQUERQUE NM
87107-2805
US

IV. Provider business mailing address

1849 CALLE LOS VECINOS NW
ALBUQUERQUE NM
87107-2805
US

V. Phone/Fax

Practice location:
  • Phone: 505-321-7804
  • Fax:
Mailing address:
  • Phone: 505-321-7804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number2262
License Number StateNM

VIII. Authorized Official

Name: MISS KRISTINA M SAMPSEL
Title or Position: PRESIDENT
Credential: MOTR/L
Phone: 505-321-7804