MEDICARE: RESTORE OCCUPATIONAL AND PHYSICAL THERAPY SPEECH LANGUAGE

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	171W00000X	Contractor		NY

General Provider Information

NPI Number	:	1679946586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORE OCCUPATIONAL AND PHYSICAL THERAPY SPEECH LANGUAGE

Provider Business Mailing Address
First Line	:	81 MOHAWK ST
Second Line	:	PO BOX 367
City	:	COHOES
State	:	NY
Zip	:	12047-2809
Country	:	US
Telephone Number	:	518-235-2329
Fax Number	:	518-235-9791

Provider Business Practice Location Address
First Line	:	81 MOHAWK ST
Second Line	:
City	:	COHOES
State	:	NY
Zip	:	12047-2809
Country	:	US
Telephone Number	:	518-235-2329
Fax Number	:	518-235-9791

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JODI A. HAGUE
Credential	:
Telephone Number	:	518-235-2329

Provider Enumeration Date	:	11/02/2015
Last Update Date	:	04/14/2016

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Directions to “RESTORE OCCUPATIONAL AND PHYSICAL THERAPY SPEECH LANGUAGE ” Practice Location

Language	Start Address	Practice Location

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