Provider Demographics
NPI:1154572352
Name:DERMODY, KIM SU ANN (LMT)
Entity type:Individual
Prefix:
First Name:KIM SU
Middle Name:ANN
Last Name:DERMODY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SOUND RD
Mailing Address - Street 2:D
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-1033
Mailing Address - Country:US
Mailing Address - Phone:631-886-1999
Mailing Address - Fax:
Practice Address - Street 1:2 SOUND RD
Practice Address - Street 2:D
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-1033
Practice Address - Country:US
Practice Address - Phone:631-886-1999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011574225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist