Provider Demographics
NPI:1922639954
Name:POLLEY, KENDY R (COTA/L)
Entity Type:Individual
Prefix:
First Name:KENDY
Middle Name:R
Last Name:POLLEY
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 1:101 OLIVIA DR
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-1388
Mailing Address - Country:US
Mailing Address - Phone:618-771-2141
Mailing Address - Fax:
Practice Address - Street 1:1050 N REED STATION RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-7376
Practice Address - Country:US
Practice Address - Phone:618-519-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004923224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant