MEDICARE: GELLA MATATOVA OTR

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	019138-1	NY

General Provider Information

NPI Number	:	1518194950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GELLA MATATOVA OTR

Provider Business Mailing Address
First Line	:	102-18 62ND AVE
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1042
Country	:	US
Telephone Number	:	718-810-3219
Fax Number	:

Provider Business Practice Location Address
First Line	:	10218 62ND AVE
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1042
Country	:	US
Telephone Number	:	718-896-8162
Fax Number	:

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

Provider Enumeration Date	:	06/12/2009
Last Update Date	:	11/20/2015

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