MEDICARE: MS. JILL WISNIEWSKI MS OTR/L

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	016326-1	NY

General Provider Information

NPI Number	:	1043806631
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JILL WISNIEWSKI MS OTR/L

Provider Business Mailing Address
First Line	:	117 TRAVERSE BLVD
Second Line	:
City	:	TONAWANDA
State	:	NY
Zip	:	14223-1013
Country	:	US
Telephone Number	:	716-440-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	117 TRAVERSE BLVD
Second Line	:
City	:	TONAWANDA
State	:	NY
Zip	:	14223-1013
Country	:	US
Telephone Number	:	716-440-2700
Fax Number	:

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

Provider Enumeration Date	:	12/17/2020
Last Update Date	:	12/17/2020

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