MEDICARE: VIVIANETTE MENENDEZ NIEVES OTRL

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	0119008961	VA

General Provider Information

NPI Number	:	1205535713
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIANETTE MENENDEZ NIEVES OTRL

Provider Business Mailing Address
First Line	:	3301 MCCLELLAN DR
Second Line	:
City	:	FREDERICKSBURG
State	:	VA
Zip	:	22408-0296
Country	:	US
Telephone Number	:	787-671-7593
Fax Number	:

Provider Business Practice Location Address
First Line	:	16 IRVING AVE N
Second Line	:
City	:	COLONIAL BEACH
State	:	VA
Zip	:	22443-2324
Country	:	US
Telephone Number	:	787-671-7593
Fax Number	:

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

Provider Enumeration Date	:	02/23/2023
Last Update Date	:	02/23/2023

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