Provider Demographics
NPI:1396375168
Name:YEBOAH, EDMUND (OTR)
Entity Type:Individual
Prefix:
First Name:EDMUND
Middle Name:
Last Name:YEBOAH
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 OXFORD RD APT 23C
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-4325
Mailing Address - Country:US
Mailing Address - Phone:646-804-8774
Mailing Address - Fax:
Practice Address - Street 1:245 OXFORD RD APT 23C
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-4325
Practice Address - Country:US
Practice Address - Phone:646-804-8774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024354225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist