Provider Demographics
NPI:1154960540
Name:DEROGATIS, KATHLEEN A
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:DEROGATIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 GARDEN PL
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803-3206
Mailing Address - Country:US
Mailing Address - Phone:914-260-3264
Mailing Address - Fax:
Practice Address - Street 1:55 PALMER AVE
Practice Address - Street 2:
Practice Address - City:BRONXVILLE
Practice Address - State:NY
Practice Address - Zip Code:10708-3403
Practice Address - Country:US
Practice Address - Phone:914-787-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010621225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist