Provider Demographics
NPI:1497206353
Name:TALLARICO, KASSANDRA KITNEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:KITNEY
Last Name:TALLARICO
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 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:610-438-2020
Mailing Address - Fax:888-689-8070
Practice Address - Street 1:2755 UNION RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7015
Practice Address - Country:US
Practice Address - Phone:704-756-7476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10651225X00000X
NY020071225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist