Provider Demographics
NPI:1932470275
Name:ANDRASIK, KELLY LYNN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:ANDRASIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 WELCH RD
Mailing Address - Street 2:REHABILITATION SERVICES - 3RD FLOOR
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1601
Mailing Address - Country:US
Mailing Address - Phone:650-497-8218
Mailing Address - Fax:650-497-8491
Practice Address - Street 1:725 WELCH RD
Practice Address - Street 2:REHABILITATION SERVICES - 3RD FLOOR
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1601
Practice Address - Country:US
Practice Address - Phone:650-497-8218
Practice Address - Fax:650-497-8491
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11652225X00000X
OR238537225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA053305Medicaid
CA053305Medicaid