Provider Demographics
NPI:1558844100
Name:BENDER, KAILEY ALLYSON
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:ALLYSON
Last Name:BENDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HEMLOCK AVE
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-3412
Mailing Address - Country:US
Mailing Address - Phone:310-469-1156
Mailing Address - Fax:
Practice Address - Street 1:2521 WINDWARD WAY
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-4526
Practice Address - Country:US
Practice Address - Phone:619-621-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19185225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist