Provider Demographics
NPI:1023396405
Name:BIRDSALL, KANDICE (MOT, LOTR)
Entity Type:Individual
Prefix:
First Name:KANDICE
Middle Name:
Last Name:BIRDSALL
Suffix:
Gender:F
Credentials:MOT, LOTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W 134TH ST
Mailing Address - Street 2:
Mailing Address - City:CUT OFF
Mailing Address - State:LA
Mailing Address - Zip Code:70345-4155
Mailing Address - Country:US
Mailing Address - Phone:985-632-7919
Mailing Address - Fax:
Practice Address - Street 1:104 W 134TH ST
Practice Address - Street 2:
Practice Address - City:CUT OFF
Practice Address - State:LA
Practice Address - Zip Code:70345-4155
Practice Address - Country:US
Practice Address - Phone:985-632-7919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAOTT.200467225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist