MEDICARE: MISS OLGA KHAZANOVA 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	225XP0200X	Pediatric Occupational Therapist	014497	NY

General Provider Information

NPI Number	:	1669614566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS OLGA KHAZANOVA OTR

Provider Business Mailing Address
First Line	:	2554 HARWAY AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-6623
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2554 HARWAY AVE FL 2
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-6623
Country	:	US
Telephone Number	:	718-372-4586
Fax Number	:

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

Provider Enumeration Date	:	03/24/2009
Last Update Date	:	03/24/2009

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