Provider Demographics
NPI:1619626900
Name:KEBEDE, BAMLAKU (OTA)
Entity Type:Individual
Prefix:
First Name:BAMLAKU
Middle Name:
Last Name:KEBEDE
Suffix:
Gender:M
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:977 E NEW LONDON DR
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66061-7117
Mailing Address - Country:US
Mailing Address - Phone:913-232-3577
Mailing Address - Fax:
Practice Address - Street 1:3811 W 52ND ST
Practice Address - Street 2:
Practice Address - City:ROELAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66205-1458
Practice Address - Country:US
Practice Address - Phone:913-579-8556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS470224224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSYBC15K024376Medicaid