Provider Demographics
NPI:1477016137
Name:CUNDIFF, KRISTEN BLAIR (COTA/L)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:BLAIR
Last Name:CUNDIFF
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 1:204 HICKORY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 FOXHALL ROAD
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:NC
Practice Address - Zip Code:28570-5285
Practice Address - Country:US
Practice Address - Phone:252-223-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0131-002155224Z00000X
NC14201224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant