Provider Demographics
NPI:1851857536
Name:BOMBA, KAITLIN MARIE (COTA)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:BOMBA
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 CALUMET AVE
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311-1963
Mailing Address - Country:US
Mailing Address - Phone:219-313-2555
Mailing Address - Fax:
Practice Address - Street 1:212 BARNEY DR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5271
Practice Address - Country:US
Practice Address - Phone:815-725-2194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant