Basic Information
| Provider Information | |||||||||
| NPI: | 1497009369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARBST | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | DEREK | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2557 14TH ST APT 1 | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111023720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6078218421 | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 E SHORE RD | ||||||||
| Address2: | |||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110232409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166841122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2012 | ||||||||
| LastUpdateDate: | 10/31/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | 002123 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.