MEDICARE: MARIA CHARISSE JUDILLA GASTADOR 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	225XP0200X	Pediatric Occupational Therapist	013827-1	NY

General Provider Information

NPI Number	:	1740591809
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA CHARISSE JUDILLA GASTADOR OTR/L

Provider Business Mailing Address
First Line	:	5009 38TH ST
Second Line	:	3F
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-1901
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5009 38TH ST
Second Line	:	3F
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-1901
Country	:	US
Telephone Number	:	917-774-0968
Fax Number	:

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

Provider Enumeration Date	:	06/23/2010
Last Update Date	:	02/28/2011

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