Basic Information
| Provider Information | |||||||||
| NPI: | 1225016751 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOTTFRIED RANDALL | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | O.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | SUITE 6600 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057244384 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 CEDAR ST SE | ||||||||
| Address2: | SUITE 6600 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057244300 | ||||||||
| FaxNumber: | 5057244384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 11/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 1799 | NM | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 09821325 | 05 | NM | MEDICAID |