MEDICARE: MS. THEA SAMIT 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	1041C0700X	Clinical Social Worker	44SC04713000	NJ
2	225X00000X	Occupational Therapist	003816-1	NY
3	225X00000X	Occupational Therapist	OT 5124	FL

General Provider Information

NPI Number	:	1629380340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. THEA SAMIT OTR

Provider Business Mailing Address
First Line	:	308 HARRISON AVE
Second Line	:
City	:	HIGHLAND PARK
State	:	NJ
Zip	:	08904-1836
Country	:	US
Telephone Number	:	732-247-0161
Fax Number	:	732-247-2790

Provider Business Practice Location Address
First Line	:	4151 E. 11 ST.
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	33009-1836
Country	:	US
Telephone Number	:	732-247-0161
Fax Number	:	732-247-2790

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

Provider Enumeration Date	:	07/10/2010
Last Update Date	:	07/10/2010

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