Provider Demographics
NPI:1164707840
Name:BANDI, KIM (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:BANDI
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 1:551 E STATION AVE
Mailing Address - Street 2:
Mailing Address - City:COOPERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18036-2027
Mailing Address - Country:US
Mailing Address - Phone:484-863-9220
Mailing Address - Fax:
Practice Address - Street 1:551 E STATION AVE
Practice Address - Street 2:
Practice Address - City:COOPERSBURG
Practice Address - State:PA
Practice Address - Zip Code:18036-2027
Practice Address - Country:US
Practice Address - Phone:484-863-9220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2016-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC007396L171W00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1164707840Medicaid
PA1164707840Medicare UPIN
PA1164707840Medicare Oscar/Certification
PA1164707840Medicare PIN
PA1164707840Medicare NSC