Provider Demographics
NPI:1366279234
Name:KOUTSANTANOU, ISABELLA MAYA (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:ISABELLA
Middle Name:MAYA
Last Name:KOUTSANTANOU
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ALDEN DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-1404
Mailing Address - Country:US
Mailing Address - Phone:631-413-7601
Mailing Address - Fax:
Practice Address - Street 1:800 E GATE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-2105
Practice Address - Country:US
Practice Address - Phone:516-745-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029334225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist