=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811363724
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVEWELL OCCUPATIONAL THERAPY SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2015
-----------------------------------------------------
Last Update Date | 09/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1999 MARCUS AVE STE M15
-----------------------------------------------------
City | LAKE SUCCESS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11042-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-488-8808
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24222 54TH AVE
-----------------------------------------------------
City | DOUGLASTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11362-1507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-466-1529
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MBR, OCCUPATIONAL THERAPIST
-----------------------------------------------------
Name | MS. MILENA ALICANDRO
-----------------------------------------------------
Credential | O.T.R/L
-----------------------------------------------------
Telephone | 347-466-1529
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | 004958-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------