Provider Demographics
NPI:1295569051
Name:GRANDE, KRYSTA ANN (BA, COTA/L)
Entity type:Individual
Prefix:
First Name:KRYSTA
Middle Name:ANN
Last Name:GRANDE
Suffix:
Gender:F
Credentials:BA, COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6521 CAROLINE AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-1441
Mailing Address - Country:US
Mailing Address - Phone:609-680-6004
Mailing Address - Fax:
Practice Address - Street 1:3260 TILLMAN DR STE 117
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-2058
Practice Address - Country:US
Practice Address - Phone:267-332-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOP009745224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant