Basic Information
| Provider Information | |||||||||
| NPI: | 1871144139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SONG | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | EUNBI | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JEONG | ||||||||
| OtherFirstName: | GRACE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3342 149TH ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113543242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6462668564 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 90 E SHORE RD | ||||||||
| Address2: | |||||||||
| City: | GREAT NECK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 110232409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166841122 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2019 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 044918-01 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.