Healthcare Provider Details

I. General information

NPI: 1649714783
Provider Name (Legal Business Name): NATHALIE JAE COLMENARES LIEBOWITZ COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NATHALIE JAE COLMENARES LARRACAS

II. Dates (important events)

Enumeration Date: 12/08/2016
Last Update Date: 06/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4277 65TH PL
WOODSIDE NY
11377-5054
US

IV. Provider business mailing address

5314 94TH ST
ELMHURST NY
11373-4632
US

V. Phone/Fax

Practice location:
  • Phone: 718-429-2000
  • Fax:
Mailing address:
  • Phone: 347-209-7567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number009334
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: