=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245948595
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAE ISABEL LORO MONTALBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2022
-----------------------------------------------------
Last Update Date | 11/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 575 8TH AVE FL 6
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-3158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-286-5260
-----------------------------------------------------
Fax | 917-286-5296
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 575 8TH AVE FL 6
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10018-3158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-286-5260
-----------------------------------------------------
Fax | 917-286-5296
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 025717
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------