Provider Demographics
NPI:1962800631
Name:JUDAN, BERNALYN (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:BERNALYN
Middle Name:
Last Name:JUDAN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 33RD RD
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-4243
Mailing Address - Country:US
Mailing Address - Phone:347-272-0295
Mailing Address - Fax:
Practice Address - Street 1:2307 33RD RD
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-4243
Practice Address - Country:US
Practice Address - Phone:347-272-0295
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-12
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019208225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist