Provider Demographics
NPI:1497194617
Name:ST MARYS HEALTHCARE SYSTEM FOR CHILDREN
Entity Type:Organization
Organization Name:ST MARYS HEALTHCARE SYSTEM FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:SUMMERS
Authorized Official - Last Name:KAMBOURIAN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:303-681-1136
Mailing Address - Street 1:1638 JASMINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040
Mailing Address - Country:US
Mailing Address - Phone:303-681-1136
Mailing Address - Fax:
Practice Address - Street 1:1638 JASMINE AVE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4339
Practice Address - Country:US
Practice Address - Phone:303-681-1136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization