=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013480730
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANA D CRAFT MS ED
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2019
-----------------------------------------------------
Last Update Date | 01/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 179 ESSEX ST
-----------------------------------------------------
City | MONTAUK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11954-5406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-268-4809
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 983
-----------------------------------------------------
City | MONTAUK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11954-0801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-668-6244
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------