MEDICARE: MARY BRYDA 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	46TR00632700	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	46TR00632700	OTHER	NJ	NEW JERSEY OCCUPATIONAL THERAPY COUNCIL

General Provider Information

NPI Number	:	1780050245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY BRYDA OTR/L

Provider Business Mailing Address
First Line	:	77 BROOK AVE APT F2
Second Line	:
City	:	PASSAIC
State	:	NJ
Zip	:	07055-5372
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6612 BERGENLINE AVE
Second Line	:
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093-1719
Country	:	US
Telephone Number	:	201-861-0182
Fax Number	:

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

Provider Enumeration Date	:	08/19/2015
Last Update Date	:	08/19/2015

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Directions to “ MARY BRYDA OTR/L” Practice Location

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