Provider Demographics
NPI:1619635455
Name:IKEDA, KIRSTIN (MS OTR/L)
Entity Type:Individual
Prefix:
First Name:KIRSTIN
Middle Name:
Last Name:IKEDA
Suffix:
Gender:F
Credentials:MS OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 REMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-2326
Mailing Address - Country:US
Mailing Address - Phone:410-430-0237
Mailing Address - Fax:
Practice Address - Street 1:3502 SCOTTS LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1561
Practice Address - Country:US
Practice Address - Phone:410-430-0237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics