=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639122948
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELISSA MICHELE FIORITO OTR/L, CLT-LANA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 WALL ST SUITE 100
-----------------------------------------------------
City | WEST LONG BRANCH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07764-1181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-222-8556
-----------------------------------------------------
Fax | 732-222-8663
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 305 PROVINCIAL DR
-----------------------------------------------------
City | MORGANVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07751-4163
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-591-1685
-----------------------------------------------------
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 | 46TR00074700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------