1306098553 NPI number — CREATIVE WONDERS OT PT SLP PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306098553 NPI number — CREATIVE WONDERS OT PT SLP PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREATIVE WONDERS OT PT SLP PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306098553
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
470 MAMARONECK AVE STE 412
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITE PLAINS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10605-1839
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-421-8270
Provider Business Mailing Address Fax Number:
914-421-8272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
470 MAMARONECK AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
WHITE PLAINS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10605-1830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-421-8270
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/21/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER AND DIRECTOR
Authorized Official Telephone Number:
914-421-8270

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 252Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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