MEDICARE: NICOLE BRADLEY 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	006887-1	NY

General Provider Information

NPI Number	:	1033315585
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE BRADLEY OTA

Provider Business Mailing Address
First Line	:	7 BARTLETT DR
Second Line	:
City	:	MIDDLETOWN
State	:	NY
Zip	:	10941-1001
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 WINDGATE WAY
Second Line	:
City	:	HIGHLAND
State	:	NY
Zip	:	12528-2143
Country	:	US
Telephone Number	:	845-691-6800
Fax Number	:	845-691-2858

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

Provider Enumeration Date	:	06/22/2007
Last Update Date	:	07/08/2007

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