=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649545450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUFFOLK OCCUPATIONAL THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2012
-----------------------------------------------------
Last Update Date | 02/08/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 187 UNION AVE
-----------------------------------------------------
City | ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11751-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-581-5607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 187 UNION AVE
-----------------------------------------------------
City | ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11751-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-581-5607
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | JOHN A SHARPE
-----------------------------------------------------
Credential | MS OTR/L
-----------------------------------------------------
Telephone | 631-581-5607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 63 009116
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------