Provider Demographics
NPI:1629491220
Name:LEBEDEVA O'DONNELL, KSENIA (PTA)
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:LEBEDEVA O'DONNELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 EVERETT AVE
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-2376
Mailing Address - Country:US
Mailing Address - Phone:844-744-4200
Mailing Address - Fax:
Practice Address - Street 1:70 EVERETT AVE
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-2376
Practice Address - Country:US
Practice Address - Phone:844-744-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8221225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant