Provider Demographics
NPI:1508061706
Name:ESCOBAR, JUAN MANUEL (OTR)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MANUEL
Last Name:ESCOBAR
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 1:317 BOGHT RD
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:NY
Mailing Address - Zip Code:12189-1106
Mailing Address - Country:US
Mailing Address - Phone:850-624-4010
Mailing Address - Fax:
Practice Address - Street 1:317 BOGHT RD
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:NY
Practice Address - Zip Code:12189-1106
Practice Address - Country:US
Practice Address - Phone:850-624-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00426500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist