Provider Demographics
NPI:1174750384
Name:DALY, KEVIN JAMES (OTR/L)
Entity type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:DALY
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2756
Mailing Address - Country:US
Mailing Address - Phone:703-966-7868
Mailing Address - Fax:
Practice Address - Street 1:183 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2756
Practice Address - Country:US
Practice Address - Phone:703-966-7868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-15
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCOT010000440225X00000X
GAOT002773225X00000X
NY009133-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000845413BMedicaid