Basic Information
| Provider Information | |||||||||
| NPI: | 1811135460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REARDON | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | COTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 CHRISTIAN STREET | ||||||||
| Address2: | BOX 170 | ||||||||
| City: | HARTFORD | ||||||||
| State: | VT | ||||||||
| PostalCode: | 050470170 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 290 HANOVER STREET | ||||||||
| Address2: | |||||||||
| City: | CLAREMONT | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03743 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035422606 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2009 | ||||||||
| LastUpdateDate: | 02/04/2009 | ||||||||
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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 | 224Z00000X | 81 | NH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.