Healthcare Provider Details

I. General information

NPI: 1336406230
Provider Name (Legal Business Name): SUSAN ELIZABETH YOUNG O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 04/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 STILLWATER AVE
MASSAPEQUA NY
11758-8419
US

IV. Provider business mailing address

11 STILLWATER AVE
MASSAPEQUA NY
11758-8419
US

V. Phone/Fax

Practice location:
  • Phone: 516-799-1359
  • Fax: 516-799-1359
Mailing address:
  • Phone: 516-799-1359
  • Fax: 516-799-1359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number005988-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: