Provider Demographics
NPI:1043549389
Name:DODDERER, KRISTEN (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:DODDERER
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, OTR/L
Mailing Address - Street 1:5310 GLEN VISTA DR
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75044-4662
Mailing Address - Country:US
Mailing Address - Phone:501-352-1319
Mailing Address - Fax:
Practice Address - Street 1:4443 N JOSEY LN
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4743
Practice Address - Country:US
Practice Address - Phone:972-394-8900
Practice Address - Fax:972-394-6266
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-16
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120473225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist