Basic Information
| Provider Information | |||||||||
| NPI: | 1003003377 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRENDERGAST | ||||||||
| FirstName: | KATHLEEN | ||||||||
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| Credential: | OTR, LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9568 DARIEN RD | ||||||||
| Address2: | |||||||||
| City: | WEST FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141709611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165607315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141411442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7165607315 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2007 | ||||||||
| LastUpdateDate: | 10/01/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 014927-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.