=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457630071
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RENA NAN LIU OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2011
-----------------------------------------------------
Last Update Date | 08/12/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2350 WATERS EDGE DR APT 5T
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-502-9407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2350 WATERS EDGE DRIVE APT 5T
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-502-9407
-----------------------------------------------------
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 |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 018125-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------