Basic Information
| Provider Information | |||||||||
| NPI: | 1477003952 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL OCCUPATIONAL & PHYSICAL THERAPY, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 576 BROADHOLLOW RD | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117475002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313595859 | ||||||||
| FaxNumber: | 6313960865 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071051558 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734916500 | ||||||||
| FaxNumber: | 9734916303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2016 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | BRUSH | ||||||||
| AuthorizedOfficialFirstName: | KATHLEEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7188196805 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.