MEDICARE: ROSA MARIA NIEVES OTA

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	224Z00000X	Occupational Therapy Assistant	005453	NY

General Provider Information

NPI Number	:	1710525084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSA MARIA NIEVES OTA

Provider Business Mailing Address
First Line	:	1810 STOCKHOLM ST APT 2L
Second Line	:
City	:	RIDGEWOOD
State	:	NY
Zip	:	11385-1322
Country	:	US
Telephone Number	:	347-255-6637
Fax Number	:

Provider Business Practice Location Address
First Line	:	6135 DRY HARBOR RD
Second Line	:
City	:	MIDDLE VILLAGE
State	:	NY
Zip	:	11379-1599
Country	:	US
Telephone Number	:	718-565-4262
Fax Number	:

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

Provider Enumeration Date	:	12/17/2019
Last Update Date	:	12/17/2019

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