1144507559 NPI number — MS. COLONETTE JANE BURLEIGH P.T.

Table of content: MS. COLONETTE JANE BURLEIGH P.T. (NPI 1144507559)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144507559 NPI number — MS. COLONETTE JANE BURLEIGH P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURLEIGH
Provider First Name:
COLONETTE
Provider Middle Name:
JANE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144507559
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 CHAMPLAIN AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TICONDEROGA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12883-1313
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-585-2202
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2758 MAIN STREET
Provider Second Line Business Practice Location Address:
CROWN POINT CENTRAL SCHOOL
Provider Business Practice Location Address City Name:
CROWN POINT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12928-0035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-597-3285
Provider Business Practice Location Address Fax Number:
518-597-4121
Provider Enumeration Date:
11/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  001663-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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