Provider Demographics
NPI:1174343818
Name:OT SOURCE PC
Entity type:Organization
Organization Name:OT SOURCE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARISSA
Authorized Official - Middle Name:CAYABYAB
Authorized Official - Last Name:AQUINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-288-8011
Mailing Address - Street 1:1335 E 66TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5632
Mailing Address - Country:US
Mailing Address - Phone:718-288-8011
Mailing Address - Fax:
Practice Address - Street 1:1335 E 66TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5632
Practice Address - Country:US
Practice Address - Phone:718-288-8011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist