Provider Demographics
NPI:1306988597
Name:QUEZADA, KELLY (COTA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:QUEZADA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 MOUNTAINSIDE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELDS
Mailing Address - State:NY
Mailing Address - Zip Code:10975-2632
Mailing Address - Country:US
Mailing Address - Phone:845-351-5551
Mailing Address - Fax:845-564-6974
Practice Address - Street 1:904 MOUNTAINSIDE DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELDS
Practice Address - State:NY
Practice Address - Zip Code:10975-2632
Practice Address - Country:US
Practice Address - Phone:845-351-5551
Practice Address - Fax:845-564-6974
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004529-1224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY004529-1OtherCOTA LICENSE