Provider Demographics
NPI:1366501702
Name:KAHLBAUGH, MARK CHARLES (OT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:CHARLES
Last Name:KAHLBAUGH
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2093 E WILLOW WICK RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-2747
Mailing Address - Country:US
Mailing Address - Phone:480-205-6917
Mailing Address - Fax:480-361-4420
Practice Address - Street 1:2093 E WILLOW WICK RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-2747
Practice Address - Country:US
Practice Address - Phone:480-205-6917
Practice Address - Fax:480-361-4420
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2559225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2559OtherAZ STATE OT LICENSE