MEDICARE: LORI FERNANDEZ 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	007309-1	NY

General Provider Information

NPI Number	:	1902171135
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORI FERNANDEZ OTR/L

Provider Business Mailing Address
First Line	:	80 MCARTHUR AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-1925
Country	:	US
Telephone Number	:	917-749-0845
Fax Number	:

Provider Business Practice Location Address
First Line	:	30 NATICK ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-1617
Country	:	US
Telephone Number	:	718-351-1155
Fax Number	:

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

Provider Enumeration Date	:	03/21/2012
Last Update Date	:	03/21/2012

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