Provider Demographics
NPI:1205294691
Name:PROVIDER REHAB, OT. P.C.
Entity type:Organization
Organization Name:PROVIDER REHAB, OT. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DMITRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEVCHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:347-766-9077
Mailing Address - Street 1:3030 EMMONS AVE APT 5T
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2228
Mailing Address - Country:US
Mailing Address - Phone:347-766-9077
Mailing Address - Fax:
Practice Address - Street 1:288 SAND LN STE 1
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-4512
Practice Address - Country:US
Practice Address - Phone:347-766-9077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-01
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63018851225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty