Basic Information
| Provider Information | |||||||||
| NPI: | 1417151176 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VANDECARR | ||||||||
| OtherFirstName: | KRISTINA | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11 N 5 POINTS RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193804778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4842660387 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11 N 5 POINTS RD STE 2 | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193804778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4842660387 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OC008525 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | OC008525 | 01 | PA | OCCUPATIONAL THERAPIST | OTHER |