MEDICARE: MRS. SARAH CROUCH DEROUIN 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	225XP0200X	Pediatric Occupational Therapist	008177-1	NY

General Provider Information

NPI Number	:	1326291980
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARAH CROUCH DEROUIN OTR/L

Provider Business Mailing Address
First Line	:	15800 MILITARY RD
Second Line	:
City	:	SACKETS HARBOR
State	:	NY
Zip	:	13685-3110
Country	:	US
Telephone Number	:	315-778-2812
Fax Number	:	315-639-3337

Provider Business Practice Location Address
First Line	:	15800 MILITARY RD
Second Line	:
City	:	SACKETS HARBOR
State	:	NY
Zip	:	13685-3110
Country	:	US
Telephone Number	:	315-778-2812
Fax Number	:	315-639-3337

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

Provider Enumeration Date	:	10/28/2008
Last Update Date	:	10/28/2008

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