Provider Demographics
NPI:1598096844
Name:PREMOCK, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:PREMOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 TOWNSEND RD
Mailing Address - Street 2:
Mailing Address - City:MARMORA
Mailing Address - State:NJ
Mailing Address - Zip Code:08223-1133
Mailing Address - Country:US
Mailing Address - Phone:941-223-5994
Mailing Address - Fax:866-426-2811
Practice Address - Street 1:917 BEVILLE RD
Practice Address - Street 2:SUITE G
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1712
Practice Address - Country:US
Practice Address - Phone:386-756-4395
Practice Address - Fax:866-426-2811
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09070500224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant