MEDICARE: ALIA BOYNTON OTD, 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	225XM0800X	Mental Health Occupational Therapist	OC019642	PA
2	225X00000X	Occupational Therapist	OC019642	PA
3	225XE0001X	Environmental Modification Occupational Therapist	OC019642	PA

General Provider Information

NPI Number	:	1154190536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALIA BOYNTON OTD, OTR/L

Provider Business Mailing Address
First Line	:	1005 SPRUCE ST APT 3R
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-6710
Country	:	US
Telephone Number	:	858-412-9685
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 S 2ND ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19147-1731
Country	:	US
Telephone Number	:	856-409-0275
Fax Number	:

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

Provider Enumeration Date	:	12/27/2023
Last Update Date	:	12/27/2023

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