Provider Demographics
NPI:1871014134
Name:SANFORD, KELLY LYNN (COTA/L)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:SANFORD
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3240 OLD BETHLEHEM PIKE
Mailing Address - Street 2:
Mailing Address - City:COOPERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18036-2808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:307 W 38TH ST RM 1305
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-9521
Practice Address - Country:US
Practice Address - Phone:212-943-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATOP009133224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant