Healthcare Provider Details

I. General information

NPI: 1407000995
Provider Name (Legal Business Name): MIND AND BODY OCCUPATIONAL THERAPY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W 135TH ST 2S
NEW YORK NY
10030-2731
US

IV. Provider business mailing address

PO BOX 653
NEW YORK NY
10030-0600
US

V. Phone/Fax

Practice location:
  • Phone: 917-603-2385
  • Fax: 212-368-1241
Mailing address:
  • Phone: 917-603-2385
  • Fax: 212-368-1241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number009959-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number009959-1
License Number StateNY

VIII. Authorized Official

Name: BRIGITTE CARIDAD DESPORT
Title or Position: PRESIDENT
Credential: MS, OTR/L
Phone: 917-603-2385