Basic Information
| Provider Information | |||||||||
| NPI: | 1740509694 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFESTYLE OCCUPATIONAL THERAPY, PLLC | ||||||||
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| OtherOrganizationName: | DAVID GROVER OTR L | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 921 DEWITT ST #2 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154228822 | ||||||||
| FaxNumber: | 3152952125 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 1ST ST | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130885108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154228822 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2010 | ||||||||
| LastUpdateDate: | 10/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | GROVER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3154228822 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | OTR L | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 007946 | NY | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 225X00000X | 012318 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.