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General NPI Number Information
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NPI Number | 1316577307
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Entity Type | Organization
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Legal Business Name | INTERACTIVE CREATIVE THERAPY INC
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Dates
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Enumeration Date | 01/19/2020
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Last Update Date | 01/19/2020
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Provider Practice Location Address
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Address Line | 18 W 21ST ST
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City | DEER PARK
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State | NY
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Zip | 11729-3918
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Country | US
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Telephone | 631-306-4053
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Fax |
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Provider Business Mailing Address
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Address Line | 25 MASSACHUSETTS AVE
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-6101
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Country | US
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Telephone | 631-790-2584
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DECHANTAL MONTANO
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Credential | OT
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Telephone | 580-402-6704
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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