=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487292785
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COURTNEY TAYLOR BANKS OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2019
-----------------------------------------------------
Last Update Date | 12/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 LAKE ST
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12754-1966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-292-4200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 SOUTHGATE RD APT 25
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10940-2056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-267-8493
-----------------------------------------------------
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 | 19486
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 022053
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------