Provider Demographics
NPI:1164812764
Name:RODRIGUEZ, KIMBERLY (COTA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 CORNELIA ST
Mailing Address - Street 2:APT 2R
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-4936
Mailing Address - Country:US
Mailing Address - Phone:646-742-7412
Mailing Address - Fax:
Practice Address - Street 1:2085 VISTA PKWY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-2719
Practice Address - Country:US
Practice Address - Phone:561-471-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008598-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant