1497205959 NPI number — PROFESSIONAL OCCUPATIONAL & PHYSICAL THERAPY, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497205959 NPI number — PROFESSIONAL OCCUPATIONAL & PHYSICAL THERAPY, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL OCCUPATIONAL & PHYSICAL THERAPY, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1497205959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
576 BROADHOLLOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11747-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-359-5859
Provider Business Mailing Address Fax Number:
631-396-0865

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 BRIGHTON RD
Provider Second Line Business Practice Location Address:
SUITE 406
Provider Business Practice Location Address City Name:
CLIFTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07012-1663
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-928-6969
Provider Business Practice Location Address Fax Number:
973-928-6968
Provider Enumeration Date:
10/09/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BRUSH
Authorized Official First Name:
KATHLEEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
718-819-6805

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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