Provider Demographics
NPI:1952052417
Name:GAYNOR, AMANDA RAE (OTR/L)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:GAYNOR
Suffix:
Gender:F
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 1:1159 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-2632
Mailing Address - Country:US
Mailing Address - Phone:631-944-2479
Mailing Address - Fax:
Practice Address - Street 1:1772 E JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-5763
Practice Address - Country:US
Practice Address - Phone:631-368-2583
Practice Address - Fax:631-368-5357
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026495225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics