Provider Demographics
NPI:1457502965
Name:ELLEFSEN, KRISTI (COTA)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:ELLEFSEN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6807 PINE ROCK CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-3405
Mailing Address - Country:US
Mailing Address - Phone:801-259-0732
Mailing Address - Fax:
Practice Address - Street 1:6807 PINE ROCK CIR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-3405
Practice Address - Country:US
Practice Address - Phone:801-259-0732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2008-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4738858-4202224Z00000X
WAOC 60038172224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant