=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316203946
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUMP START THERAPY PLACE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2012
-----------------------------------------------------
Last Update Date | 10/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4131 RICHMOND AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-5633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-351-0308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4131 RICHMOND AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10312-5633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-351-0308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. YELENA NEMTSOVA
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 917-622-2612
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 006852
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 05516
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------