=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306146337
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANASTASIA GARRUSS OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2010
-----------------------------------------------------
Last Update Date | 04/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 WALNUT ST
-----------------------------------------------------
City | NEWTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02460-1691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-523-6958
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 381 WESTERN AVE APT 3
-----------------------------------------------------
City | CAMBRIDGE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02139-3740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-523-6958
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 11050
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------