Provider Demographics
NPI:1598855850
Name:WAANDERS, KELLY DAWN (OTR)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:DAWN
Last Name:WAANDERS
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5985 S BIRCH WAY
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80121-3306
Mailing Address - Country:US
Mailing Address - Phone:720-493-0777
Mailing Address - Fax:
Practice Address - Street 1:5985 S BIRCH WAY
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80121-3306
Practice Address - Country:US
Practice Address - Phone:720-493-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO985050225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO70281327Medicaid