Provider Demographics
NPI:1881659878
Name:LAVELLE, KATHLEEN ROSE (OT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:LAVELLE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-1051
Mailing Address - Country:US
Mailing Address - Phone:716-684-0400
Mailing Address - Fax:716-683-7028
Practice Address - Street 1:4039 ROUTE 219
Practice Address - Street 2:SUITE 104
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779
Practice Address - Country:US
Practice Address - Phone:716-945-2484
Practice Address - Fax:716-945-2487
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000670089001OtherBLUE CROSS BLUE SHIELD
NY02143882Medicaid
NY827101OtherMANAGED PHYSICAL NETWORK
NY00011174501OtherUNIVERA
NY040426003615OtherFIDELIS
NY9611230OtherIHA
NYCC7580Medicare ID - Type Unspecified
NY02143882Medicaid