=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437401999
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S.R.OCCUPATIONAL & MASSAGE THERAPY,PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2012
-----------------------------------------------------
Last Update Date | 10/09/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20920 33RD RD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-403-4448
-----------------------------------------------------
Fax | 718-224-3129
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20920 33RD RD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-1421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-403-4448
-----------------------------------------------------
Fax | 718-224-3129
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. SUSAN A RONIS
-----------------------------------------------------
Credential | MSOTRLMT
-----------------------------------------------------
Telephone | 917-403-4448
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 003946-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------