Provider Demographics
NPI:1669006649
Name:MITZENMACHER, KRISTIN DANIELLE (OTR/L, MS)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:DANIELLE
Last Name:MITZENMACHER
Suffix:
Gender:F
Credentials:OTR/L, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:5175 ANDREW JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92057-4404
Mailing Address - Country:US
Mailing Address - Phone:909-260-4931
Mailing Address - Fax:
Practice Address - Street 1:2909A CARLETON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2713
Practice Address - Country:US
Practice Address - Phone:619-795-7790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20957225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics