Healthcare Provider Details

I. General information

NPI: 1982974200
Provider Name (Legal Business Name): STEPHANIE HEINZ MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 SUMMIT AVE
STATEN ISLAND NY
10306-1352
US

IV. Provider business mailing address

15 BIRCHARD AVE
STATEN ISLAND NY
10314-4134
US

V. Phone/Fax

Practice location:
  • Phone: 718-979-5678
  • Fax:
Mailing address:
  • Phone: 917-902-1663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number017092
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: