Provider Demographics
NPI:1164920500
Name:FUNDAMENTAL PLAY OCCUPATIONAL THERAPY P C
Entity Type:Organization
Organization Name:FUNDAMENTAL PLAY OCCUPATIONAL THERAPY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:MAZOL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVYDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:917-499-1224
Mailing Address - Street 1:6545 PARSONS BLVD APT 3J
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2419
Mailing Address - Country:US
Mailing Address - Phone:917-499-1224
Mailing Address - Fax:
Practice Address - Street 1:6545 PARSONS BLVD APT 3J
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-2419
Practice Address - Country:US
Practice Address - Phone:917-499-1224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020599225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty