Provider Demographics
NPI:1811135460
Name:REARDON, KIM MARIE (COTAL)
Entity type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:REARDON
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 CHRISTIAN STREET
Mailing Address - Street 2:BOX 170
Mailing Address - City:HARTFORD
Mailing Address - State:VT
Mailing Address - Zip Code:05047-0170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:290 HANOVER STREET
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743
Practice Address - Country:US
Practice Address - Phone:603-542-2606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH81224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant