MEDICARE: JULIETTE LYN DOHERTY 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	225X00000X	Occupational Therapist	012457-1	NY
2	225XP0200X	Pediatric Occupational Therapist	012457-1	NY

General Provider Information

NPI Number	:	1649431339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JULIETTE LYN DOHERTY OTR/L

Provider Business Mailing Address
First Line	:	239 BOYLE RD STE 3
Second Line	:
City	:	SELDEN
State	:	NY
Zip	:	11784-1955
Country	:	US
Telephone Number	:	631-929-3306
Fax Number	:

Provider Business Practice Location Address
First Line	:	239 BOYLE RD STE 3
Second Line	:
City	:	SELDEN
State	:	NY
Zip	:	11784-1955
Country	:	US
Telephone Number	:	631-929-3306
Fax Number	:

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

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	11/18/2019

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