Healthcare Provider Details

I. General information

NPI: 1043668718
Provider Name (Legal Business Name): KADDI LUCAS OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KADDI DILLEN

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 W 23RD ST STE 1
ERIE PA
16506-5802
US

IV. Provider business mailing address

419 WATERFORD ST
EDINBORO PA
16412-5517
US

V. Phone/Fax

Practice location:
  • Phone: 814-456-2755
  • Fax: 814-456-4873
Mailing address:
  • Phone: 814-734-5021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberTOC103210
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: