Basic Information
| Provider Information | |||||||||
| NPI: | 1366952038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VINEBERG | ||||||||
| FirstName: | CHRISTY | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FAVINGER | ||||||||
| OtherFirstName: | CHRISTY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4002 N WARNER RD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE HILL | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194441409 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 536 OLD HOWELL RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296151969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642443626 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2017 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0019X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Physical Rehabilitation | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.