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General NPI Number Information
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NPI Number | 1306063789
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Entity Type | Individual
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Provider Name | KRISTIN FORMAN C.O.T.A.
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Gender | Female
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Dates
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Enumeration Date | 04/19/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | LIBERTY COURT 1560 LOMBARD STREET
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City | PHILADELPHIA
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State | PA
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Zip | 19146
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Country | US
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Telephone | 215-546-5960
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Fax |
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Provider Business Mailing Address
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Address Line | 101 YALE SQ
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City | MORTON
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State | PA
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Zip | 19070-1925
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Country | US
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Telephone | 610-604-9878
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | OP003620L
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License Number State | PA
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