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General NPI Number Information
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NPI Number | 1164588158
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Entity Type | Individual
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Provider Name | TELISA T WARDLAW OTR
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Gender | Female
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 01/19/2012
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Provider Practice Location Address
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Address Line | 220-28 147TH AVENUE
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City | ROSEDALE
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State | NY
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Zip | 11413
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Country | US
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Telephone | 718-276-1600
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Fax |
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Provider Business Mailing Address
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Address Line | 17030 130TH AVE APT 13A
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City | JAMAICA
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State | NY
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Zip | 11434-6002
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Country | US
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Telephone | 917-650-1126
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 016130-1
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License Number State | NY
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