Basic Information
| Provider Information | |||||||||
| NPI: | 1881659878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAVELLE | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | OT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 TRANSIT RD | ||||||||
| Address2: | |||||||||
| City: | DEPEW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140431051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166840400 | ||||||||
| FaxNumber: | 7166837028 | ||||||||
| Practice Location | |||||||||
| Address1: | 4039 ROUTE 219 | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SALAMANCA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7169452484 | ||||||||
| FaxNumber: | 7169452487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 000670089001 | 01 | NY | BLUE CROSS BLUE SHIELD | OTHER | 02143882 | 05 | NY | MEDICAID | 827101 | 01 | NY | MANAGED PHYSICAL NETWORK | OTHER | 00011174501 | 01 | NY | UNIVERA | OTHER | 040426003615 | 01 | NY | FIDELIS | OTHER | 9611230 | 01 | NY | IHA | OTHER |