Provider Demographics
NPI:1538770086
Name:STREET, KATHLEEN ANNE (OTR)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANNE
Last Name:STREET
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31038 W ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:AZ
Mailing Address - Zip Code:85396-5374
Mailing Address - Country:US
Mailing Address - Phone:856-558-2880
Mailing Address - Fax:
Practice Address - Street 1:14505 W GRANITE VALLEY DR
Practice Address - Street 2:
Practice Address - City:SUN CITY WEST
Practice Address - State:AZ
Practice Address - Zip Code:85375-5795
Practice Address - Country:US
Practice Address - Phone:623-975-8100
Practice Address - Fax:623-975-8222
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTH-003355225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty