Healthcare Provider Details

I. General information

NPI: 1285040956
Provider Name (Legal Business Name): KIMBERLY HANNA-OSULLIVAN O.T.R./L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 CAMINO DE MONTE REY LIFESPAN THERAPY SERVICES
SANTA FE NM
87505-3977
US

IV. Provider business mailing address

27 BOSQUE AZUL
SANTA FE NM
87507-9429
US

V. Phone/Fax

Practice location:
  • Phone: 505-954-9940
  • Fax:
Mailing address:
  • Phone: 505-603-5901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number3244
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: