=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962824185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOVEMENT POTENTIAL NY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2014
-----------------------------------------------------
Last Update Date | 01/07/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16328 19TH AVE
-----------------------------------------------------
City | WHITESTONE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11357-3339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-826-7715
-----------------------------------------------------
Fax | 718-352-9440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16328 19TH AVE
-----------------------------------------------------
City | WHITESTONE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11357-3339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-826-7715
-----------------------------------------------------
Fax | 718-352-9440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. SONIA R ORTIZ
-----------------------------------------------------
Credential | MA, PT
-----------------------------------------------------
Telephone | 917-826-7715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 007955
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------