Basic Information
Provider Information
NPI: 1003003377
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PRENDERGAST
FirstName: KATHLEEN
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: OTR, LMT
OtherOrganizationName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 9568 DARIEN RD
Address2:  
City: WEST FALLS
State: NY
PostalCode: 141709611
CountryCode: US
TelephoneNumber: 7165607315
FaxNumber:  
Practice Location
Address1: 210 E MAIN ST
Address2:  
City: SPRINGVILLE
State: NY
PostalCode: 141411442
CountryCode: US
TelephoneNumber: 7165607315
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/01/2007
LastUpdateDate: 10/01/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
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IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
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AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225700000X014927-1NYY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist 

No ID Information.


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