Provider Demographics
NPI:1649614371
Name:THOMAS, TIMOTHY BERNARD (COTA/L)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:BERNARD
Last Name:THOMAS
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17025 HIGHLAND AVE
Mailing Address - Street 2:#4C
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2752
Mailing Address - Country:US
Mailing Address - Phone:646-621-8829
Mailing Address - Fax:
Practice Address - Street 1:17025 HIGHLAND AVE
Practice Address - Street 2:#4C
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-2752
Practice Address - Country:US
Practice Address - Phone:646-621-8829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000604-1224Z00000X
FLOTA10692224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant