Provider Demographics
NPI:1205076239
Name:FONDA-EWING, KELLY C (MSOTR/L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:C
Last Name:FONDA-EWING
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:NY
Mailing Address - Zip Code:12189-3805
Mailing Address - Country:US
Mailing Address - Phone:518-892-8468
Mailing Address - Fax:
Practice Address - Street 1:435 4TH ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-5324
Practice Address - Country:US
Practice Address - Phone:518-271-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-04
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017202-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist