MEDICARE: MRS. KATHLEEN MARIE MICHAELIDES

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	225XP0200X	Pediatric Occupational Therapist	014831	NY

General Provider Information

NPI Number	:	1003182429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLEEN MARIE MICHAELIDES

Provider Business Mailing Address
First Line	:	44 SALISBURY RUN
Second Line	:
City	:	MOUNT SINAI
State	:	NY
Zip	:	11766-2823
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3425 82ND ST
Second Line	:
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-2967
Country	:	US
Telephone Number	:	718-898-6973
Fax Number	:

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

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	03/29/2012

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