Provider Demographics
NPI:1114585791
Name:VANDERBILT, KRISTINA MARIE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:VANDERBILT
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 1:637 E MOWRY CT
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-8207
Mailing Address - Country:US
Mailing Address - Phone:305-748-7863
Mailing Address - Fax:
Practice Address - Street 1:8181 NW 36TH ST STE 18
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6661
Practice Address - Country:US
Practice Address - Phone:305-591-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19970225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist