Provider Demographics
NPI:1053915744
Name:CHRISTIANSEN, KELLIE (OTR/L)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:CHRISTIANSEN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2360 NEW JERUSALEM RD
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14057-9587
Mailing Address - Country:US
Mailing Address - Phone:716-263-4421
Mailing Address - Fax:
Practice Address - Street 1:5285 LEWISTON RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1942
Practice Address - Country:US
Practice Address - Phone:716-298-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-24
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025262225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist