Healthcare Provider Details

I. General information

NPI: 1316577307
Provider Name (Legal Business Name): INTERACTIVE CREATIVE THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2020
Last Update Date: 01/19/2020
Certification Date: 01/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 W 21ST ST
DEER PARK NY
11729-3918
US

IV. Provider business mailing address

25 MASSACHUSETTS AVE
PORT JEFFERSON STATION NY
11776-6101
US

V. Phone/Fax

Practice location:
  • Phone: 631-306-4053
  • Fax:
Mailing address:
  • Phone: 631-790-2584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DECHANTAL MONTANO
Title or Position: PRESIDENT
Credential: OT
Phone: 580-402-6704