Provider Demographics
NPI:1376074609
Name:BLANK, KIRSTIE R (COTA/L)
Entity Type:Individual
Prefix:
First Name:KIRSTIE
Middle Name:R
Last Name:BLANK
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 BAILEY CROSSROADS RD
Mailing Address - Street 2:
Mailing Address - City:ATGLEN
Mailing Address - State:PA
Mailing Address - Zip Code:19310-9688
Mailing Address - Country:US
Mailing Address - Phone:610-350-1090
Mailing Address - Fax:
Practice Address - Street 1:600 E ROSEVILLE RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4288
Practice Address - Country:US
Practice Address - Phone:717-381-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP008686224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant