Provider Demographics
NPI:1225016751
Name:GOTTFRIED RANDALL, KATHRYN R (OT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:R
Last Name:GOTTFRIED RANDALL
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6265 ROCK CHALK DR STE 1700
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-5232
Mailing Address - Country:US
Mailing Address - Phone:785-838-7885
Mailing Address - Fax:785-838-7885
Practice Address - Street 1:6265 ROCK CHALK DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-5232
Practice Address - Country:US
Practice Address - Phone:785-838-7885
Practice Address - Fax:785-505-5311
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1799225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM09821325Medicaid
343515400Medicare ID - Type Unspecified