Provider Demographics
NPI:1447283882
Name:DIVERSIFIED SERVICES FOR OCCUPATIONAL THERAPY, PHYSICAL THER
Entity type:Organization
Organization Name:DIVERSIFIED SERVICES FOR OCCUPATIONAL THERAPY, PHYSICAL THER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUTTADAURIA
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:716-871-9883
Mailing Address - Street 1:2900 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-2309
Mailing Address - Country:US
Mailing Address - Phone:716-871-9883
Mailing Address - Fax:716-871-9887
Practice Address - Street 1:2900 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2309
Practice Address - Country:US
Practice Address - Phone:716-871-9883
Practice Address - Fax:716-871-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001149231H00000X
NY000846235Z00000X
332BX2000X, 332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332S00000XSuppliersHearing Aid EquipmentGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02671290Medicaid
NY02700365Medicaid
NY02690875Medicaid
NY01806404Medicaid
NY02690884Medicaid
NY02667421Medicaid
NY02690884Medicaid