=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770150500
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTEN TAYLOR QUIJADA OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2021
-----------------------------------------------------
Last Update Date | 09/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2150 LEXINGTON RD STE A&B
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40475-7924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-353-5445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 354 PEACHTREE DR
-----------------------------------------------------
City | BEREA
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40403-9128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-339-8079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 269019
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------