Provider Demographics
NPI:1003419896
Name:ENERIO, THARA KRISTELLE (PT)
Entity Type:Individual
Prefix:
First Name:THARA KRISTELLE
Middle Name:
Last Name:ENERIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 62ND ST
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2147
Mailing Address - Country:US
Mailing Address - Phone:908-416-3155
Mailing Address - Fax:
Practice Address - Street 1:26717 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1743
Practice Address - Country:US
Practice Address - Phone:718-343-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043504-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation