Provider Demographics
NPI:1942803192
Name:BOMGARDNER, KENDRA L (MOT, ORT/L)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:L
Last Name:BOMGARDNER
Suffix:
Gender:F
Credentials:MOT, ORT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:914-294-4050
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:680 KINGSBOROUGH SQ STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4988
Practice Address - Country:US
Practice Address - Phone:757-547-0434
Practice Address - Fax:757-547-0612
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0119008823225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist