MEDICARE: MRS. LARISSA BELTRAO GOMES 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	9147	NY

General Provider Information

NPI Number	:	1871719534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LARISSA BELTRAO GOMES OT

Provider Business Mailing Address
First Line	:	522 GREGORY AVE APT B305
Second Line	:
City	:	WEEHAWKEN
State	:	NJ
Zip	:	07086-5750
Country	:	US
Telephone Number	:	646-431-1739
Fax Number	:

Provider Business Practice Location Address
First Line	:	522 GREGORY AVE APT B305
Second Line	:
City	:	WEEHAWKEN
State	:	NJ
Zip	:	07086-5750
Country	:	US
Telephone Number	:	646-431-1739
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	12/09/2014

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