Provider Demographics
NPI:1558611392
Name:HIRSCHBOCK, KELLY ANNE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANNE
Last Name:HIRSCHBOCK
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 1:3885 PROSPECT ST.
Mailing Address - Street 2:
Mailing Address - City:ONEIDA
Mailing Address - State:NY
Mailing Address - Zip Code:13421-5202
Mailing Address - Country:US
Mailing Address - Phone:315-269-4462
Mailing Address - Fax:
Practice Address - Street 1:171 INTREPID LN
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-2548
Practice Address - Country:US
Practice Address - Phone:315-437-4689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017502-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics