Healthcare Provider Details

I. General information

NPI: 1205940517
Provider Name (Legal Business Name): LISA E KEDRON OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 CHERYL LN
DEPEW NY
14043-1415
US

IV. Provider business mailing address

152 CHERYL LN
DEPEW NY
14043-1415
US

V. Phone/Fax

Practice location:
  • Phone: 716-445-5588
  • Fax: 888-619-0673
Mailing address:
  • Phone: 716-445-5588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number010746-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: