1114051018 NPI number — MRS. KRISTINA KAY WARREN MOT,OT/L

Table of content: MRS. KRISTINA KAY WARREN MOT,OT/L (NPI 1114051018)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114051018 NPI number — MRS. KRISTINA KAY WARREN MOT,OT/L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WARREN
Provider First Name:
KRISTINA
Provider Middle Name:
KAY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MOT,OT/L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114051018
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4405 LYNHURST RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62711-7131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-891-1524
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3050 MONTVALE DR SUITE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62704-9415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-891-1524
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  31004218A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X , with the licence number: 056008995 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200688260 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".