Healthcare Provider Details

I. General information

NPI: 1962929943
Provider Name (Legal Business Name): JACQUELINE ANNE RASTU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SCHINDLER CT APT 3
MIDDLETOWN NY
10940-2020
US

IV. Provider business mailing address

192 TOWER DR STE 400
MIDDLETOWN NY
10941-2057
US

V. Phone/Fax

Practice location:
  • Phone: 631-455-5828
  • Fax:
Mailing address:
  • Phone: 845-692-4391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: