Provider Demographics
NPI:1033374210
Name:VESPER, SALLY AGNES (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:AGNES
Last Name:VESPER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 PORTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-9113
Mailing Address - Country:US
Mailing Address - Phone:716-655-5476
Mailing Address - Fax:
Practice Address - Street 1:1511 PORTERVILLE RD
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-9113
Practice Address - Country:US
Practice Address - Phone:716-655-5476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-27
Last Update Date:2008-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007192-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYDD5778Medicare PIN