=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376293498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DISTANCE THERAPIES OCCUPATIONAL THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2022
-----------------------------------------------------
Last Update Date | 03/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 ROUTE 146 STE 494
-----------------------------------------------------
City | CLIFTON PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12065-3910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-209-9648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 82 SOUTHBURY RD
-----------------------------------------------------
City | CLIFTON PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12065-7709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MS. JENNIFER OLIVER
-----------------------------------------------------
Credential | MS, OTR/L
-----------------------------------------------------
Telephone | 518-209-9648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------