Provider Demographics
NPI:1649567520
Name:FEDERGRUN, TSIPPORA (OT)
Entity Type:Individual
Prefix:MRS
First Name:TSIPPORA
Middle Name:
Last Name:FEDERGRUN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 BANCROFT RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-3227
Mailing Address - Country:US
Mailing Address - Phone:410-358-1996
Mailing Address - Fax:866-840-6040
Practice Address - Street 1:6414 PARK HEIGHTS AVE
Practice Address - Street 2:SUITE T1
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-3055
Practice Address - Country:US
Practice Address - Phone:410-358-1997
Practice Address - Fax:866-840-6040
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06482225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics