=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265035059
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTA ECKELS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2020
-----------------------------------------------------
Last Update Date | 11/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4164 STATE LINE RD
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66103-3329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-214-2215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4164 STATE LINE RD
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66103-3329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-214-2215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XH1300X
-----------------------------------------------------
Taxonomy Name | Human Factors Occupational Therapist
-----------------------------------------------------
License Number | 17-03476
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 17-03476
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------