Provider Demographics
NPI:1649393901
Name:NIEDBALA, KRISTIN MARIE (OTR)
Entity Type:Individual
Prefix:MISS
First Name:KRISTIN
Middle Name:MARIE
Last Name:NIEDBALA
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 1:1825 W RAY RD
Mailing Address - Street 2:#2097
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-4056
Mailing Address - Country:US
Mailing Address - Phone:602-615-1932
Mailing Address - Fax:
Practice Address - Street 1:8115 E INDIAN BEND RD
Practice Address - Street 2:STE 123
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85250-4819
Practice Address - Country:US
Practice Address - Phone:480-951-6451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3245225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist