Provider Demographics
NPI:1497101943
Name:HANSBERRY, KIRAN C
Entity Type:Individual
Prefix:
First Name:KIRAN
Middle Name:C
Last Name:HANSBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIRAN
Other - Middle Name:C
Other - Last Name:SIDHWANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5119 CRYSTAL PARK LN
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-7947
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11512 LAKE MEAD AVE UNIT 604
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9686
Practice Address - Country:US
Practice Address - Phone:904-652-5408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-13
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07798225X00000X
FLOT20423225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist