Provider Demographics
NPI:1700195302
Name:TAN, RITA MAE (OTRL)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:MAE
Last Name:TAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11203 111TH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-1118
Mailing Address - Country:US
Mailing Address - Phone:718-738-0475
Mailing Address - Fax:
Practice Address - Street 1:11515 101ST AVE
Practice Address - Street 2:
Practice Address - City:SOUTH RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11419-1247
Practice Address - Country:US
Practice Address - Phone:718-441-5333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008595-1225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008595-1OtherNYS LICENSE NUMBER