MEDICARE: SPROUTS OCCUPATIONAL THERAPY LLC

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	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1013568237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPROUTS OCCUPATIONAL THERAPY LLC

Provider Business Mailing Address
First Line	:	17 CREST DR
Second Line	:
City	:	MIDLAND PARK
State	:	NJ
Zip	:	07432-1312
Country	:	US
Telephone Number	:	201-252-7070
Fax Number	:

Provider Business Practice Location Address
First Line	:	17 CREST DR
Second Line	:
City	:	MIDLAND PARK
State	:	NJ
Zip	:	07432-1312
Country	:	US
Telephone Number	:	201-280-1739
Fax Number	:

Authorized Official
Title or Position	:	OCCUPATIONAL THERAPIST
Name	:	KIMBERLY SUSAN AIELLO
Credential	:	MSOT
Telephone Number	:	201-252-7070

Provider Enumeration Date	:	09/29/2019
Last Update Date	:	09/29/2019

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