Basic Information
| Provider Information | |||||||||
| NPI: | 1841604923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEROSA | ||||||||
| FirstName: | GERI | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MALDONADO | ||||||||
| OtherFirstName: | GERI | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY STE 307 | ||||||||
| Address2: | |||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6315805200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 80 MILL ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078601411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739407311 | ||||||||
| FaxNumber: | 9739407342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01549300 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.