Provider Demographics
NPI:1376964908
Name:BUDNICK, KELLY NICOLE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NICOLE
Last Name:BUDNICK
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 1:801 SE PARK CREST AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-1300
Mailing Address - Country:US
Mailing Address - Phone:360-260-2200
Mailing Address - Fax:
Practice Address - Street 1:801 SE PARK CREST AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-1300
Practice Address - Country:US
Practice Address - Phone:360-260-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-28
Last Update Date:2013-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60127249225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4112819Medicaid
WA505389Medicare UPIN