Provider Demographics
NPI:1346750866
Name:GAZELKA, KATHERINE MICHELLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MICHELLE
Last Name:GAZELKA
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 1:30041 TESSIER APT 292
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-8912
Mailing Address - Country:US
Mailing Address - Phone:218-255-2725
Mailing Address - Fax:
Practice Address - Street 1:1085 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-2023
Practice Address - Country:US
Practice Address - Phone:909-877-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21973225X00000X
MN105507225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1346750866Medicaid