=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467786632
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELAINA ANDERSEN OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2009
-----------------------------------------------------
Last Update Date | 03/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 907 SYCAMORE AVENUE
-----------------------------------------------------
City | BOHEMIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-786-7532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 907 SYCAMORE AVE
-----------------------------------------------------
City | BOHEMIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11716-3516
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-786-7532
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 015357-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------