=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659885010
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FABIOLA LECONTE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2017
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 BROADWAY AVE
-----------------------------------------------------
City | SAYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11782-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-567-9300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 LITTLE EAST NECK RD
-----------------------------------------------------
City | WYANDANCH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11798-4203
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-445-3406
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 217321
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------