Provider Demographics
NPI:1780881516
Name:PEDERSEN, KRISTEN LEIGH (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:LEIGH
Last Name:PEDERSEN
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 1:2878 E RED CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-6201
Mailing Address - Country:US
Mailing Address - Phone:208-930-4181
Mailing Address - Fax:
Practice Address - Street 1:920 W IRONWOOD DR
Practice Address - Street 2:SUITE 207
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2463
Practice Address - Country:US
Practice Address - Phone:208-664-0575
Practice Address - Fax:208-664-0576
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOT-912225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
16545051Medicare UPIN