Provider Demographics
NPI:1871961268
Name:AOTA
Entity type:Organization
Organization Name:AOTA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COTA
Authorized Official - Prefix:MS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:DEROSS
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:845-492-6752
Mailing Address - Street 1:PO BOX 1394
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10925-1394
Mailing Address - Country:US
Mailing Address - Phone:845-492-6752
Mailing Address - Fax:
Practice Address - Street 1:27 LAKE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-3521
Practice Address - Country:US
Practice Address - Phone:845-492-6752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-02
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004814-1302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0048141OtherCOTA