Basic Information
| Provider Information | |||||||||
| NPI: | 1750471124 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THERA DYNAMIC PHYSICAL THERAPY P.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1443 28TH AVE APT 2D | ||||||||
| Address2: | |||||||||
| City: | LONG ISLAND CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111023663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189394166 | ||||||||
| FaxNumber: | 3477329011 | ||||||||
| Practice Location | |||||||||
| Address1: | 13329 41ST RD STE 1A | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113553671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189394166 | ||||||||
| FaxNumber: | 3477329011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 02/02/2021 | ||||||||
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| AuthorizedOfficialLastName: | ANDRES | ||||||||
| AuthorizedOfficialFirstName: | LEE-ZEL MAY | ||||||||
| AuthorizedOfficialMiddleName: | CARINGAL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7189394166 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | 02/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 025591-0 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 02837832 | 05 | NY | MEDICAID | 2766209 | 01 | NY | UNITED HEALTHCARE | OTHER | P4059437 | 01 | NY | OXFORD FREEDOM | OTHER | PH0434 | 01 | NY | ELDER PLAN | OTHER | 01941401 | 01 | NY | EMPIRE BCBS HEALTHPLUS | OTHER | 1263296P | 01 | NY | EMBLEM HEALTH | OTHER | 82ADC1 | 01 | NY | EMPIRE BCBS | OTHER | 1760591465-01 | 01 | NY | VILLAGE CARE | OTHER | 841087 | 01 | NY | OPTUM HEALTH | OTHER | PT025591-A85 | 01 | NY | HEALTHFIRST | OTHER | OP025591 | 01 | NY | METROPLUS | OTHER |