Provider Demographics
NPI:1144793316
Name:OUTPATIENT MOBILE
Entity Type:Organization
Organization Name:OUTPATIENT MOBILE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OTD OTR/L
Authorized Official - Phone:607-643-2178
Mailing Address - Street 1:113 LABBY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH GROSVENORDALE
Mailing Address - State:CT
Mailing Address - Zip Code:06255-1247
Mailing Address - Country:US
Mailing Address - Phone:607-643-2178
Mailing Address - Fax:
Practice Address - Street 1:113 LABBY RD
Practice Address - Street 2:
Practice Address - City:NORTH GROSVENORDALE
Practice Address - State:CT
Practice Address - Zip Code:06255-1247
Practice Address - Country:US
Practice Address - Phone:607-643-2178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty