Provider Demographics
NPI:1013493378
Name:BOSTON, KATHERINE ANN (OTR/L)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:BOSTON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:ANN
Other - Last Name:WONDRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4980 W SAHARA AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-3435
Mailing Address - Country:US
Mailing Address - Phone:702-820-5070
Mailing Address - Fax:
Practice Address - Street 1:4980 W SAHARA AVE STE 260
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-3435
Practice Address - Country:US
Practice Address - Phone:702-820-5070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK135672225X00000X
NVOT-2316225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1685621Medicaid