MEDICARE: SENSORY BOUNCE, LLC

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	46TR00169900	NJ

General Provider Information

NPI Number	:	1639685399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENSORY BOUNCE, LLC

Provider Business Mailing Address
First Line	:	16-00 ROUTE 208
Second Line	:
City	:	FAIR LAWN
State	:	NJ
Zip	:	07410-2503
Country	:	US
Telephone Number	:	201-759-4465
Fax Number	:

Provider Business Practice Location Address
First Line	:	16-00 ROUTE 208
Second Line	:
City	:	FAIR LAWN
State	:	NJ
Zip	:	07410-2503
Country	:	US
Telephone Number	:	201-759-4465
Fax Number	:	201-759-4465

Authorized Official
Title or Position	:	FOUNDER, DIRECTOR
Name	:	MRS. MIRIAM B SKYDELL
Credential	:	MS, OTR/L
Telephone Number	:	201-794-7700

Provider Enumeration Date	:	12/18/2017
Last Update Date	:	12/18/2017

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