Basic Information
| Provider Information | |||||||||
| NPI: | 1285389882 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ABOUFAZELI | ||||||||
| FirstName: | MAHNAZ | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1311 MAMARONECK AVE STE 140 | ||||||||
| Address2: | |||||||||
| City: | WHITE PLAINS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 106055224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142944050 | ||||||||
| FaxNumber: | 6317608306 | ||||||||
| Practice Location | |||||||||
| Address1: | 109 CROFTON PL | ||||||||
| Address2: | |||||||||
| City: | PALMYRA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229633300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4345899588 | ||||||||
| FaxNumber: | 4345894096 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2022 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305215296 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.