Provider Demographics
NPI:1912281569
Name:IPPOLITO, DAWN BUCKOVINSKY (OTR/L)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:BUCKOVINSKY
Last Name:IPPOLITO
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 1:6 RAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1427
Mailing Address - Country:US
Mailing Address - Phone:631-294-6316
Mailing Address - Fax:631-775-0233
Practice Address - Street 1:6 RAYMOND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1427
Practice Address - Country:US
Practice Address - Phone:631-294-6316
Practice Address - Fax:631-775-0233
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY63014871225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification