Healthcare Provider Details

I. General information

NPI: 1144793316
Provider Name (Legal Business Name): OUTPATIENT MOBILE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LABBY RD
NORTH GROSVENORDALE CT
06255-1247
US

IV. Provider business mailing address

113 LABBY RD
NORTH GROSVENORDALE CT
06255-1247
US

V. Phone/Fax

Practice location:
  • Phone: 607-643-2178
  • Fax:
Mailing address:
  • Phone: 607-643-2178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: TANYA LEE CLARK
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTD OTR/L
Phone: 607-643-2178