Provider Demographics
NPI:1679946586
Name:RESTORE OCCUPATIONAL AND PHYSICAL THERAPY SPEECH LANGUAGE
Entity Type:Organization
Organization Name:RESTORE OCCUPATIONAL AND PHYSICAL THERAPY SPEECH LANGUAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-235-2329
Mailing Address - Street 1:81 MOHAWK ST
Mailing Address - Street 2:PO BOX 367
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-2809
Mailing Address - Country:US
Mailing Address - Phone:518-235-2329
Mailing Address - Fax:518-235-9791
Practice Address - Street 1:81 MOHAWK ST
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047-2809
Practice Address - Country:US
Practice Address - Phone:518-235-2329
Practice Address - Fax:518-235-9791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty