=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639488026
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA MARY MALLOY-BUONANNO O.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2010
-----------------------------------------------------
Last Update Date | 10/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57 COLONIAL ST
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-6101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-462-1081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 COLONIAL ST
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-6101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-462-1081
-----------------------------------------------------
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 | 005929-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------