Basic Information
| Provider Information | |||||||||
| NPI: | 1023529609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FROISETH | ||||||||
| FirstName: | MEGHAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLIFTON | ||||||||
| OtherFirstName: | MEGHAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2142 UTOPIA PKWY | ||||||||
| Address2: | |||||||||
| City: | WHITESTONE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113574142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188196800 | ||||||||
| FaxNumber: | 9293811014 | ||||||||
| Practice Location | |||||||||
| Address1: | 74 COMMERCE AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | RIVERHEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 119013105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313399110 | ||||||||
| FaxNumber: | 6313399004 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2017 | ||||||||
| LastUpdateDate: | 12/24/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/24/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 021835 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 021835 | 01 | NY | LICENSE | OTHER |