Healthcare Provider Details

I. General information

NPI: 1043234982
Provider Name (Legal Business Name): VAN HUFFINE I OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10787 RANDOLPH ST
WINFIELD IN
46307-7615
US

IV. Provider business mailing address

1311 MAMARONECK AVE STE 140
WHITE PLAINS NY
10605-5224
US

V. Phone/Fax

Practice location:
  • Phone: 219-333-5900
  • Fax: 219-359-2123
Mailing address:
  • Phone: 914-294-4050
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number056006795
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number31003369A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: