Healthcare Provider Details

I. General information

NPI: 1255468336
Provider Name (Legal Business Name): DANIELLE GENAWAY OTRL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 DEERING CT
MEDFORD NY
11763-4085
US

IV. Provider business mailing address

4 DEERING CT
MEDFORD NY
11763-4085
US

V. Phone/Fax

Practice location:
  • Phone: 631-286-2871
  • Fax: 631-286-2871
Mailing address:
  • Phone: 631-286-2871
  • Fax: 631-286-2871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number006610-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: