Provider Demographics
NPI:1073979191
Name:SLOG, KRISTINA (OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:SLOG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7127 GOLDCRIS LN
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18067-9747
Mailing Address - Country:US
Mailing Address - Phone:610-730-0507
Mailing Address - Fax:
Practice Address - Street 1:11011 SHERIDAN ST
Practice Address - Street 2:SUITE 209
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33026-1505
Practice Address - Country:US
Practice Address - Phone:954-431-5437
Practice Address - Fax:954-432-0202
Is Sole Proprietor?:No
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT17360225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist