Provider Demographics
NPI:1992079982
Name:KEHOE, WANDA (BS/ OTR/L)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:
Last Name:KEHOE
Suffix:
Gender:F
Credentials:BS/ OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10307-2033
Mailing Address - Country:US
Mailing Address - Phone:718-356-4789
Mailing Address - Fax:
Practice Address - Street 1:555 PAGE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10307-2033
Practice Address - Country:US
Practice Address - Phone:718-356-4789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-08
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006996-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist