MEDICARE: ANASTASSIYA VIGANDT OTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	007525-1	NY

General Provider Information

NPI Number	:	1003135468
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANASTASSIYA VIGANDT OTA

Provider Business Mailing Address
First Line	:	2606 E 15TH ST
Second Line	:	202
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3828
Country	:	US
Telephone Number	:	718-332-0080
Fax Number	:	718-332-3365

Provider Business Practice Location Address
First Line	:	2606 E 15TH ST
Second Line	:	202
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3828
Country	:	US
Telephone Number	:	718-332-0080
Fax Number	:	718-332-3365

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2010
Last Update Date	:	05/25/2010

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