Provider Demographics
NPI:1003903451
Name:TAM, CONNIE WAH (OT)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:WAH
Last Name:TAM
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 SAINT MARKS AVE
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07090-1346
Mailing Address - Country:US
Mailing Address - Phone:908-232-5290
Mailing Address - Fax:
Practice Address - Street 1:227 MADISON ST
Practice Address - Street 2:MEDICAL STAFF OFFICE, ROOM 1249
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7537
Practice Address - Country:US
Practice Address - Phone:212-238-7614
Practice Address - Fax:212-238-7009
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00766600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008593OtherNYS LICENSE#
NJ46TR00766600OtherNJ LICENSE #
NYQ199720801Medicare PIN