Provider Demographics
NPI:1104242007
Name:LEMYRE, KELLEY (COTA)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:LEMYRE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:NY
Mailing Address - Zip Code:12144-2410
Mailing Address - Country:US
Mailing Address - Phone:518-423-1595
Mailing Address - Fax:
Practice Address - Street 1:623 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4031
Practice Address - Country:US
Practice Address - Phone:518-782-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-16
Last Update Date:2014-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008374-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant