MEDICARE: FRONTIER OCCUPATIONAL THERAPY PC

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

General Provider Information

NPI Number	:	1629682646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRONTIER OCCUPATIONAL THERAPY PC

Provider Business Mailing Address
First Line	:	1005 VILLAGE BLVD S
Second Line	:
City	:	BALDWINSVILLE
State	:	NY
Zip	:	13027-3369
Country	:	US
Telephone Number	:	315-409-9980
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 VILLAGE BLVD S
Second Line	:
City	:	BALDWINSVILLE
State	:	NY
Zip	:	13027-3369
Country	:	US
Telephone Number	:	315-409-9980
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LUCRECIA AGCAOILI-WHITE
Credential	:	OT
Telephone Number	:	314-409-9980

Provider Enumeration Date	:	09/08/2020
Last Update Date	:	09/08/2020

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