Provider Demographics
NPI:1558582114
Name:KENERSON, PATRICIA (COTA)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:KENERSON
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 1:15105 S UNIVERSITY
Mailing Address - Street 2:
Mailing Address - City:DOLTON
Mailing Address - State:IL
Mailing Address - Zip Code:60419
Mailing Address - Country:US
Mailing Address - Phone:708-829-2143
Mailing Address - Fax:
Practice Address - Street 1:430 E. 162ND STREET
Practice Address - Street 2:#246
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60419
Practice Address - Country:US
Practice Address - Phone:708-466-8351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL57000065224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant