Provider Demographics
NPI:1881659878
Name:LAVELLE, KATHLEEN ROSE (OT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ROSE
Last Name:LAVELLE
Suffix:
Gender:
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?:No
Enumeration Date:2006-04-20
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
NY01085001225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00011174501OtherUNIVERA
NY827101OtherMANAGED PHYSICAL NETWORK
NY000670089001OtherBLUE CROSS BLUE SHIELD
NY02143882Medicaid
NY040426003615OtherFIDELIS
NY9611230OtherIHA
NYCC7580Medicare ID - Type Unspecified
NY02143882Medicaid