Healthcare Provider Details

I. General information

NPI: 1942117205
Provider Name (Legal Business Name): KETTLY DENIS-LAMOUR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23804 128TH AVE
ROSEDALE NY
11422-1054
US

IV. Provider business mailing address

23804 128TH AVE
ROSEDALE NY
11422-1054
US

V. Phone/Fax

Practice location:
  • Phone: 984-365-8898
  • Fax:
Mailing address:
  • Phone: 984-365-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number01525601
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: