MEDICARE: MS. GRACE ANNETTA KNIGHT O T R

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	006580-1	NY
2	225XP0200X	Pediatric Occupational Therapist	006580-1	NY

General Provider Information

NPI Number	:	1245563980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GRACE ANNETTA KNIGHT O T R

Provider Business Mailing Address
First Line	:	8234 167TH ST
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11432-1222
Country	:	US
Telephone Number	:	718-926-0236
Fax Number	:	718-969-3063

Provider Business Practice Location Address
First Line	:	1200 WATERS PLACE
Second Line	:	SECOND FLOOR
City	:	BRONX
State	:	NY
Zip	:	10461-0000
Country	:	US
Telephone Number	:	718-536-3251
Fax Number	:	718-536-3240

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2009
Last Update Date	:	09/14/2009

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