MEDICARE: MRS. DOREEN H FERTEL MA. 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	004203-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Q78911	OTHER	NY	EMPIRE BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1386897304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DOREEN H FERTEL MA. OTR/L

Provider Business Mailing Address
First Line	:	1022 78TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11228-2612
Country	:	US
Telephone Number	:	718-745-5922
Fax Number	:

Provider Business Practice Location Address
First Line	:	1022 78TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11228-2612
Country	:	US
Telephone Number	:	718-745-5922
Fax Number	:

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

Provider Enumeration Date	:	11/04/2008
Last Update Date	:	12/05/2021

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