MEDICARE: MR. LEONID YAGUDAYEV OT

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	009163-1	NY
2	225X00000X	Occupational Therapist	46TR00283000	NJ

General Provider Information

NPI Number	:	1780701854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEONID YAGUDAYEV OT

Provider Business Mailing Address
First Line	:	100 CHERRY ST
Second Line	:
City	:	FLORAL PARK
State	:	NY
Zip	:	11001-3343
Country	:	US
Telephone Number	:	201-916-8442
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 CHERRY ST
Second Line	:
City	:	FLORAL PARK
State	:	NY
Zip	:	11001-3343
Country	:	US
Telephone Number	:	201-916-8442
Fax Number	:

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

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	08/28/2012

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