MEDICARE: EVENS CLEOPHAT THERAPIST

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	0095291	NY

General Provider Information

NPI Number	:	1649439647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVENS CLEOPHAT THERAPIST

Provider Business Mailing Address
First Line	:	628 E 103RD ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-2502
Country	:	US
Telephone Number	:	718-257-1109
Fax Number	:	718-495-5873

Provider Business Practice Location Address
First Line	:	320 E 56TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11203-4706
Country	:	US
Telephone Number	:	718-495-5873
Fax Number	:	718-495-5873

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

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	06/04/2008

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