Provider Demographics
NPI:1114051018
Name:WARREN, KRISTINA KAY (MOT,OT/L)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:KAY
Last Name:WARREN
Suffix:
Gender:F
Credentials:MOT,OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 LYNHURST RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-7131
Mailing Address - Country:US
Mailing Address - Phone:217-891-1524
Mailing Address - Fax:
Practice Address - Street 1:3050 MONTVALE DR SUITE A
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-9415
Practice Address - Country:US
Practice Address - Phone:217-891-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004218A225X00000X
IL056008995225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200688260Medicaid