Provider Demographics
NPI:1104047943
Name:REYES, MAILYN FAJARDO (OTR)
Entity type:Individual
Prefix:MRS
First Name:MAILYN
Middle Name:FAJARDO
Last Name:REYES
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:MRS
Other - First Name:MAILYN
Other - Middle Name:C
Other - Last Name:FAJARDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR
Mailing Address - Street 1:1625 PUTNEY RD
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1817
Mailing Address - Country:US
Mailing Address - Phone:646-244-9947
Mailing Address - Fax:
Practice Address - Street 1:110-45 71 RD STE 1G
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-593-4121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013813225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist