MEDICARE: PROFESSIONAL OCCUPATIONAL & PHYSICAL THERAPY, PLLC

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	225100000X	Physical Therapist
2	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1497284566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL OCCUPATIONAL & PHYSICAL THERAPY, PLLC

Provider Business Mailing Address
First Line	:	576 BROADHOLLOW RD
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-5002
Country	:	US
Telephone Number	:	631-359-5859
Fax Number	:	631-396-0865

Provider Business Practice Location Address
First Line	:	94 W MAIN ST
Second Line	:
City	:	BAY SHORE
State	:	NY
Zip	:	11706-8365
Country	:	US
Telephone Number	:	631-647-9124
Fax Number	:	631-647-9128

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	KATHLEEN BRUSH
Credential	:
Telephone Number	:	631-359-5859

Provider Enumeration Date	:	06/12/2017
Last Update Date	:	04/02/2018

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