Provider Demographics
NPI:1164875274
Name:CORNERSTONE KIDS OT PC
Entity Type:Organization
Organization Name:CORNERSTONE KIDS OT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TYRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BANKS
Authorized Official - Suffix:
Authorized Official - Credentials:MSOTRL
Authorized Official - Phone:516-860-9677
Mailing Address - Street 1:3512 MILBURN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-5158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3512 MILBURN AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-5158
Practice Address - Country:US
Practice Address - Phone:516-860-9677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011886-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency