=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992265854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OT SKILLS 4 LIFE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2019
-----------------------------------------------------
Last Update Date | 03/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 888 WILLIS AVE
-----------------------------------------------------
City | ALBERTSON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11507-1957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-817-7261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 PUTNAM AVE
-----------------------------------------------------
City | JERICHO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11753-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-817-7261
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DEBRA WANDERMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-817-7261
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------