Provider Demographics
NPI:1144369612
Name:BOSCO, KELLY ANN (MS, OTRL)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:BOSCO
Suffix:
Gender:F
Credentials:MS, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 PACE CT
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4330
Mailing Address - Country:US
Mailing Address - Phone:631-539-9621
Mailing Address - Fax:
Practice Address - Street 1:49 WIRELESS BLVD
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-3935
Practice Address - Country:US
Practice Address - Phone:631-382-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011548-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics