Provider Demographics
NPI:1003565433
Name:RODDY, KRISTEN (COTA/L)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:RODDY
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 CAMBRIDGE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2443
Mailing Address - Country:US
Mailing Address - Phone:518-461-1577
Mailing Address - Fax:
Practice Address - Street 1:5317 SACANDAGA RD
Practice Address - Street 2:
Practice Address - City:GALWAY
Practice Address - State:NY
Practice Address - Zip Code:12074-2423
Practice Address - Country:US
Practice Address - Phone:518-749-3041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011049-01224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant