Provider Demographics
NPI:1003003377
Name:PRENDERGAST, KATHLEEN (OTR, LMT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PRENDERGAST
Suffix:
Gender:F
Credentials:OTR, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9568 DARIEN RD
Mailing Address - Street 2:
Mailing Address - City:WEST FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14170-9611
Mailing Address - Country:US
Mailing Address - Phone:716-560-7315
Mailing Address - Fax:
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-1442
Practice Address - Country:US
Practice Address - Phone:716-560-7315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014927-1225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist