Basic Information
Provider Information
NPI: 1114065174
EntityType: 2
ReplacementNPI:  
OrganizationName: CANI PT OT SLP & PSYCHOLOGY PLLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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Mailing Information
Address1: 19472 US ROUTE 11
Address2:  
City: WATERTOWN
State: NY
PostalCode: 136015387
CountryCode: US
TelephoneNumber: 3157826126
FaxNumber: 3157823816
Practice Location
Address1: 19472 US ROUTE 11
Address2:  
City: WATERTOWN
State: NY
PostalCode: 136015387
CountryCode: US
TelephoneNumber: 3157826126
FaxNumber: 3157823816
Other Information
ProviderEnumerationDate: 02/02/2007
LastUpdateDate: 09/16/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: PEMBERTON
AuthorizedOfficialFirstName: JAMES
AuthorizedOfficialMiddleName: FREDERICK
AuthorizedOfficialTitleorPosition: OWNER PHYSICAL THERAPIST
AuthorizedOfficialTelephone: 3157826126
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: PT
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
174400000X  Y193200000X MULTI-SPECIALTY GROUPOther Service ProvidersSpecialist 

No ID Information.


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