=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629274568
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON PAUL VAN DE VEN OTRL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 GUSTAVE L LEVY PL BOX 1674
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-6500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-241-9187
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2249 36TH ST 2ND FLOOR
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11105-2210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-726-5205
-----------------------------------------------------
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 | 009277
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------