Healthcare Provider Details

I. General information

NPI: 1255910451
Provider Name (Legal Business Name): KAITLIN BRISTOL OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 SUMMIT ST
STATEN ISLAND NY
10307-1832
US

IV. Provider business mailing address

2707 FOREST HAVEN BLVD
EDISON NJ
08817-6336
US

V. Phone/Fax

Practice location:
  • Phone: 718-984-0960
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number025474
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00977300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: