Healthcare Provider Details

I. General information

NPI: 1275338063
Provider Name (Legal Business Name): ENMANUEL MOISES ANTONIO BENCOSME ALEJO OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2025
Last Update Date: 02/15/2025
Certification Date: 02/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 RIVERSIDE DR
NEW YORK NY
10032-1007
US

IV. Provider business mailing address

50 HAVEN AVE # 92
NEW YORK NY
10032-2652
US

V. Phone/Fax

Practice location:
  • Phone: 646-774-5000
  • Fax:
Mailing address:
  • Phone: 347-841-4147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number029796
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: