Provider Demographics
NPI:1659433225
Name:KENNELTY, PETER J (COTA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:KENNELTY
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 GARDNER AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-3211
Mailing Address - Country:US
Mailing Address - Phone:914-443-6505
Mailing Address - Fax:
Practice Address - Street 1:61 GARDNER AVE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-3211
Practice Address - Country:US
Practice Address - Phone:914-443-6505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003632-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant