Basic Information
| Provider Information | |||||||||
| NPI: | 1477514677 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRELL | ||||||||
| FirstName: | JACQUILEEN | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOMACK | ||||||||
| OtherFirstName: | JACQUILEEN | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5100 W TAFT RD | ||||||||
| Address2: | SUITE 2K | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154522200 | ||||||||
| FaxNumber: | 3154522204 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 W TAFT RD | ||||||||
| Address2: | SUITE 2K | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154522200 | ||||||||
| FaxNumber: | 3154522204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 12/19/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 027850 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.