MEDICARE: PROVIDER REHAB, OT. P.C.

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	63018851	NY

General Provider Information

NPI Number	:	1205294691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDER REHAB, OT. P.C.

Provider Business Mailing Address
First Line	:	3030 EMMONS AVE APT 5T
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-2228
Country	:	US
Telephone Number	:	347-766-9077
Fax Number	:

Provider Business Practice Location Address
First Line	:	288 SAND LN STE 1
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10305-4512
Country	:	US
Telephone Number	:	347-766-9077
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. DMITRY SHEVCHENKO
Credential	:	OTR/L
Telephone Number	:	347-766-9077

Provider Enumeration Date	:	02/01/2016
Last Update Date	:	03/05/2020

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