Provider Demographics
NPI:1093226805
Name:ESSENTIAL OT, PT, SLP & PSYCHOLOGY SERVICES, PLLC
Entity Type:Organization
Organization Name:ESSENTIAL OT, PT, SLP & PSYCHOLOGY SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PROGRAMS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IDOMENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-499-8496
Mailing Address - Street 1:6390 AUSTIN ST UNIT 3C
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3016
Mailing Address - Country:US
Mailing Address - Phone:917-499-8496
Mailing Address - Fax:844-800-1470
Practice Address - Street 1:6390 AUSTIN ST APT 3C
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3016
Practice Address - Country:US
Practice Address - Phone:917-499-8496
Practice Address - Fax:844-800-1470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty