Basic Information
| Provider Information | |||||||||
| NPI: | 1720025950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KTG OCCUPATIONAL THERAPY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1651 CONEY ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112305849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189981415 | ||||||||
| FaxNumber: | 7186270040 | ||||||||
| Practice Location | |||||||||
| Address1: | 1651 CONEY ISLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112305849 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189981415 | ||||||||
| FaxNumber: | 7186270040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 07/03/2017 | ||||||||
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| AuthorizedOfficialLastName: | FOGEL | ||||||||
| AuthorizedOfficialFirstName: | SHANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7189981415 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.