=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982428785
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRIQUE HENRY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2024
-----------------------------------------------------
Last Update Date | 11/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 174 S ORANGE AVE APT 4
-----------------------------------------------------
City | SOUTH ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07079-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-626-5663
-----------------------------------------------------
Fax | 855-678-8887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 174 S ORANGE AVE APT 4
-----------------------------------------------------
City | SOUTH ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07079-2270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-626-5663
-----------------------------------------------------
Fax | 855-678-8887
-----------------------------------------------------
=====================================================
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 | 008069
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------