Provider Demographics
NPI:1740509694
Name:LIFESTYLE OCCUPATIONAL THERAPY, PLLC
Entity type:Organization
Organization Name:LIFESTYLE OCCUPATIONAL THERAPY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:GROVER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR L
Authorized Official - Phone:315-422-8822
Mailing Address - Street 1:921 DEWITT ST #2
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203
Mailing Address - Country:US
Mailing Address - Phone:315-422-8822
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:101 1ST ST
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-5108
Practice Address - Country:US
Practice Address - Phone:315-422-8822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007946225700000X
NY012318225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty