MEDICARE: KRISTIE MIDDENDORF MS, OTR/L, BCP, CLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	00791	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538788112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIE MIDDENDORF MS, OTR/L, BCP, CLC

Provider Business Mailing Address
First Line	:	6309 MICHAEL DR NE
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52411-7982
Country	:	US
Telephone Number	:	319-721-9702
Fax Number	:

Provider Business Practice Location Address
First Line	:	6309 MICHAEL DR NE
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52411-7982
Country	:	US
Telephone Number	:	954-312-3449
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2020
Last Update Date	:	05/04/2020

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