Provider Demographics
NPI:1467721266
Name:WARDELL, KATHRYN REILLY (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:REILLY
Last Name:WARDELL
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 1:4720 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CAZENOVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13035-9349
Mailing Address - Country:US
Mailing Address - Phone:315-505-6616
Mailing Address - Fax:
Practice Address - Street 1:1732 FYLER RD
Practice Address - Street 2:
Practice Address - City:CHITTENANGO
Practice Address - State:NY
Practice Address - Zip Code:13037-8522
Practice Address - Country:US
Practice Address - Phone:315-687-2669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012074-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01434959Medicaid