MEDICARE: MISS INDIA LEAH FENDERSON OTA/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	224Z00000X	Occupational Therapy Assistant	007536	NY

General Provider Information

NPI Number	:	1306127360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS INDIA LEAH FENDERSON OTA/L

Provider Business Mailing Address
First Line	:	4555 BRONX BLVD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10470-1409
Country	:	US
Telephone Number	:	347-880-4443
Fax Number	:	267-306-4417

Provider Business Practice Location Address
First Line	:	4555 BRONX BLVD
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10470-1409
Country	:	US
Telephone Number	:	347-880-4443
Fax Number	:	267-306-4417

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

Provider Enumeration Date	:	09/06/2011
Last Update Date	:	09/06/2011

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