=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982306064
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMAL THERAPY & CUSTOM CELEBRATIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2023
-----------------------------------------------------
Last Update Date | 03/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1240 PAWTUCKET AVE
-----------------------------------------------------
City | RUMFORD
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02916-1427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-301-1014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 BELFIELD DR
-----------------------------------------------------
City | JOHNSTON
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02919-1801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-301-1014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. PRISCILLA F NOVA
-----------------------------------------------------
Credential | OT/L
-----------------------------------------------------
Telephone | 401-301-1014
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XF0002X
-----------------------------------------------------
Taxonomy Name | Feeding, Eating & Swallowing Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------