=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396375168
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EDMUND YEBOAH OTR
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2020
-----------------------------------------------------
Last Update Date | 01/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 245 OXFORD RD APT 23C
-----------------------------------------------------
City | NEW HARTFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13413-4325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-804-8774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 245 OXFORD RD APT 23C
-----------------------------------------------------
City | NEW HARTFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13413-4325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-804-8774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 024354
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------