Provider Demographics
NPI:1215556428
Name:WHALLEY, RICHARD LANCE (OTD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LANCE
Last Name:WHALLEY
Suffix:
Gender:M
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 CENTRAL ISLIP BLVD
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-3908
Mailing Address - Country:US
Mailing Address - Phone:631-981-6905
Mailing Address - Fax:
Practice Address - Street 1:622 HAWKINS AVE
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-2374
Practice Address - Country:US
Practice Address - Phone:631-240-3579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024666225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist