Provider Demographics
NPI:1750809018
Name:WHYNE, RADA
Entity type:Individual
Prefix:
First Name:RADA
Middle Name:
Last Name:WHYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RADA
Other - Middle Name:
Other - Last Name:MALTSEVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:53 LANSING ST APT 1
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4307
Mailing Address - Country:US
Mailing Address - Phone:347-459-2929
Mailing Address - Fax:
Practice Address - Street 1:9475 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2212
Practice Address - Country:US
Practice Address - Phone:410-889-0727
Practice Address - Fax:410-889-0729
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC015246225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist