Basic Information
| Provider Information | |||||||||
| NPI: | 1295986636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENGEL | ||||||||
| FirstName: | JENNIE | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KANE | ||||||||
| OtherFirstName: | JENNIE | ||||||||
| OtherMiddleName: | H. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 401 LOCUST STREET | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | CORAOPOLIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151083954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122990704 | ||||||||
| FaxNumber: | 4122992823 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 LOCUST STREET | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | CORAOPOLIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151083954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122990704 | ||||||||
| FaxNumber: | 4122992823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2008 | ||||||||
| LastUpdateDate: | 12/30/2011 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | OC009529 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1023280730001 | 05 | PA | MEDICAID |