MEDICARE: THERESA VINCENT

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

General Provider Information

NPI Number	:	1124306345
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA VINCENT

Provider Business Mailing Address
First Line	:	20 LIBERTY DR
Second Line	:
City	:	BALLSTON SPA
State	:	NY
Zip	:	12020-2231
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 LIBERTY DIRVE
Second Line	:
City	:	BALLSTON SPA
State	:	NY
Zip	:	12020-0007
Country	:	US
Telephone Number	:	518-598-7525
Fax Number	:

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

Provider Enumeration Date	:	07/22/2011
Last Update Date	:	07/22/2011

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Directions to “ THERESA VINCENT ” Practice Location

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