Provider Demographics
NPI:1487944054
Name:ROSEANN VANDERBECK OTRPC
Entity type:Organization
Organization Name:ROSEANN VANDERBECK OTRPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERBECK
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:516-241-3684
Mailing Address - Street 1:71 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-4137
Mailing Address - Country:US
Mailing Address - Phone:516-241-3684
Mailing Address - Fax:516-872-4605
Practice Address - Street 1:559 ATLANTIC AVE
Practice Address - Street 2:202
Practice Address - City:EAST ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11518-1530
Practice Address - Country:US
Practice Address - Phone:516-872-4605
Practice Address - Fax:516-872-4606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002930-1252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency