Provider Demographics
NPI:1467742197
Name:SOUTH, LAURETA (OTR/L)
Entity Type:Individual
Prefix:MS
First Name:LAURETA
Middle Name:
Last Name:SOUTH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MS
Other - First Name:LAURETA
Other - Middle Name:SEVILLA
Other - Last Name:ALVAIRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:150 50TH AVE
Mailing Address - Street 2:APT 3806
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-6050
Mailing Address - Country:US
Mailing Address - Phone:917-945-0060
Mailing Address - Fax:
Practice Address - Street 1:150 50TH AVE
Practice Address - Street 2:APT 3806
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-6050
Practice Address - Country:US
Practice Address - Phone:917-945-0060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-14
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225X00000X
NY016661225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1467742197Medicare PIN