=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669889945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURIE PONTONERO OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2014
-----------------------------------------------------
Last Update Date | 07/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 543 MAPLE AVE
-----------------------------------------------------
City | REIDSVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27320-4627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-342-1382
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1404 ADAMS FARM PKWY APT N
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27407-5125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-368-7963
-----------------------------------------------------
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 | 5633
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------