Provider Demographics
NPI:1003448648
Name:NORTHBOUND OT PLLC
Entity Type:Organization
Organization Name:NORTHBOUND OT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANATOLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PIKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:212-464-8365
Mailing Address - Street 1:702 KATHLEEN PL APT 4C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5143
Mailing Address - Country:US
Mailing Address - Phone:212-464-8365
Mailing Address - Fax:347-587-1915
Practice Address - Street 1:702 KATHLEEN PL APT 4C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5143
Practice Address - Country:US
Practice Address - Phone:212-464-8365
Practice Address - Fax:347-587-1915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-11
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05245001Medicaid