1174849756 NPI number — MRS. GAIL LUCILLE NISTICO PHYSICAL THERAPY ASS

Table of content: MRS. JENNIFER L CANUL LPC (NPI 1447556089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174849756 NPI number — MRS. GAIL LUCILLE NISTICO PHYSICAL THERAPY ASS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NISTICO
Provider First Name:
GAIL
Provider Middle Name:
LUCILLE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPY ASS
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:
1174849756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
219 SEMINARY RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALLICOON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12723-5316
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-887-1956
Provider Business Mailing Address Fax Number:
845-887-1956

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
256 SUNSET LAKE RD
Provider Second Line Business Practice Location Address:
SULLIVAN COUNTY ADULT CARE CENTER
Provider Business Practice Location Address City Name:
LIBERTY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-292-5910
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2010

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: 225200000X , with the licence number:  000169-1 , 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)