MEDICARE: PHYLLIS IMADE

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	025110	NY

General Provider Information

NPI Number	:	1679172134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS IMADE

Provider Business Mailing Address
First Line	:	1168 FOREST AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-5462
Country	:	US
Telephone Number	:	646-399-6738
Fax Number	:

Provider Business Practice Location Address
First Line	:	1168 FOREST AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10456-5462
Country	:	US
Telephone Number	:	646-399-6738
Fax Number	:

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

Provider Enumeration Date	:	10/25/2020
Last Update Date	:	10/25/2020

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Directions to “ PHYLLIS IMADE ” Practice Location

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