MEDICARE: MRS. ELLEN RUSYNIAK

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	006378-1	NY
2	225XN1300X	Neurorehabilitation Occupational Therapist	006378-1	NY

General Provider Information

NPI Number	:	1487063582
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELLEN RUSYNIAK

Provider Business Mailing Address
First Line	:	7349 FAIR HAVEN RD
Second Line	:
City	:	HOMER
State	:	NY
Zip	:	13077-8710
Country	:	US
Telephone Number	:	315-399-9399
Fax Number	:

Provider Business Practice Location Address
First Line	:	2130 WEBBER RD
Second Line	:
City	:	NEW WOODSTOCK
State	:	NY
Zip	:	13122-9729
Country	:	US
Telephone Number	:	315-662-3000
Fax Number	:

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

Provider Enumeration Date	:	08/04/2014
Last Update Date	:	08/04/2014

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