Provider Demographics
NPI:1902179708
Name:TAVROFF, RUSS TODD (OTR/L)
Entity Type:Individual
Prefix:MR
First Name:RUSS
Middle Name:TODD
Last Name:TAVROFF
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 THOMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-5016
Mailing Address - Country:US
Mailing Address - Phone:516-448-6359
Mailing Address - Fax:718-763-4446
Practice Address - Street 1:58 THOMPSON AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-5016
Practice Address - Country:US
Practice Address - Phone:516-448-6359
Practice Address - Fax:718-763-4446
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012002-1225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation