Provider Demographics
NPI:1417732728
Name:HILDRETH, KYRSTYN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KYRSTYN
Middle Name:
Last Name:HILDRETH
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 1:14131 OAK KNOLL RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8822
Mailing Address - Country:US
Mailing Address - Phone:209-768-5420
Mailing Address - Fax:
Practice Address - Street 1:646 STANISLAUS AVE
Practice Address - Street 2:
Practice Address - City:ANGELS CAMP
Practice Address - State:CA
Practice Address - Zip Code:95222-9114
Practice Address - Country:US
Practice Address - Phone:209-768-5420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25083225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist