Healthcare Provider Details

I. General information

NPI: 1396375168
Provider Name (Legal Business Name): EDMUND YEBOAH OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 01/21/2020
Certification Date: 01/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 OXFORD RD APT 23C
NEW HARTFORD NY
13413-4325
US

IV. Provider business mailing address

245 OXFORD RD APT 23C
NEW HARTFORD NY
13413-4325
US

V. Phone/Fax

Practice location:
  • Phone: 646-804-8774
  • Fax:
Mailing address:
  • Phone: 646-804-8774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number024354
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: