Provider Demographics
NPI:1144381963
Name:BOETEL, KRISTINE ELAYNE (COTAL)
Entity Type:Individual
Prefix:MS
First Name:KRISTINE
Middle Name:ELAYNE
Last Name:BOETEL
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6397
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246
Mailing Address - Country:US
Mailing Address - Phone:480-820-6366
Mailing Address - Fax:480-820-0462
Practice Address - Street 1:2220 S COUNTRY CLUB
Practice Address - Street 2:#104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210
Practice Address - Country:US
Practice Address - Phone:480-820-6366
Practice Address - Fax:480-820-0462
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1909224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant