MEDICARE: MAIA DAKUZASHVILI 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	019412	NY

General Provider Information

NPI Number	:	1073049698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAIA DAKUZASHVILI OTR/L

Provider Business Mailing Address
First Line	:	6623 RIDGE BLVD
Second Line	:	APT#5F
City	:	BROOKLYN
State	:	NY
Zip	:	11220-4860
Country	:	US
Telephone Number	:	347-385-4867
Fax Number	:

Provider Business Practice Location Address
First Line	:	6623 RIDGE BLVD
Second Line	:	APT#5F
City	:	BROOKLYN
State	:	NY
Zip	:	11220-4860
Country	:	US
Telephone Number	:	347-385-4867
Fax Number	:

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

Provider Enumeration Date	:	05/02/2017
Last Update Date	:	05/02/2017

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