Provider Demographics
NPI:1245755537
Name:PARK, KATHRYN ANN (OTR/L)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:PARK
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 1:870 CHESTNUT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-2468
Mailing Address - Country:US
Mailing Address - Phone:631-882-2113
Mailing Address - Fax:
Practice Address - Street 1:1500 BRECKNOCK RD
Practice Address - Street 2:
Practice Address - City:GREENPORT
Practice Address - State:NY
Practice Address - Zip Code:11944-3117
Practice Address - Country:US
Practice Address - Phone:631-477-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020619225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist