Healthcare Provider Details

I. General information

NPI: 1770874406
Provider Name (Legal Business Name): MAXINE OREILLY OTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2011
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8780 124TH ST
RICHMOND HILL NY
11418-2733
US

IV. Provider business mailing address

8780 124TH ST
RICHMOND HILL NY
11418-2733
US

V. Phone/Fax

Practice location:
  • Phone: 646-704-1380
  • Fax:
Mailing address:
  • Phone: 646-704-1380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224ZF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapy Assistant
License Number007547-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: