Provider Demographics
NPI:1700320306
Name:KNUDSON, KENDEL S (OTD, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KENDEL
Middle Name:S
Last Name:KNUDSON
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 PORTER LN
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-4215
Mailing Address - Country:US
Mailing Address - Phone:815-985-0101
Mailing Address - Fax:
Practice Address - Street 1:2500 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9774
Practice Address - Country:US
Practice Address - Phone:815-842-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010451225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics