1710315718 NPI number — CDK ABILITIES PHYSICAL THERAPY, SPEECH LANGUAGE PATHOLOGY

Table of content: (NPI 1710315718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710315718 NPI number — CDK ABILITIES PHYSICAL THERAPY, SPEECH LANGUAGE PATHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CDK ABILITIES PHYSICAL THERAPY, SPEECH LANGUAGE PATHOLOGY
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:
6
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:
1710315718
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 BROOKFIELD RUN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUEENSBURY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12804-8796
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-307-3494
Provider Business Mailing Address Fax Number:
518-541-2091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 MAPLE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENSFALLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12801-3602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-307-3494
Provider Business Practice Location Address Fax Number:
518-541-2091
Provider Enumeration Date:
10/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DUNBAR
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER/PARTNER MANAGER
Authorized Official Telephone Number:
518-307-3494

Provider Taxonomy Codes

  • Taxonomy code: 252Y00000X , with the licence number:  006990 , 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)

  • Identifier: 03796458-CR , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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