Provider Demographics
NPI:1831854363
Name:CHULYAKOV, AMELIA (OTR/L)
Entity type:Individual
Prefix:DR
First Name:AMELIA
Middle Name:
Last Name:CHULYAKOV
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 1:36 SHAWNEE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:07866-1505
Mailing Address - Country:US
Mailing Address - Phone:201-650-0048
Mailing Address - Fax:
Practice Address - Street 1:89 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2744
Practice Address - Country:US
Practice Address - Phone:201-650-0048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-31
Last Update Date:2021-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01023100225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR01023100Medicaid