Provider Demographics
NPI:1003492091
Name:BAGONGON, MARIA HEIDI DE LOS REYES (PT)
Entity Type:Individual
Prefix:
First Name:MARIA HEIDI
Middle Name:DE LOS REYES
Last Name:BAGONGON
Suffix:
Gender:F
Credentials:PT
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3563 BAINBRIDGE AVE APT 6C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-1440
Mailing Address - Country:US
Mailing Address - Phone:617-412-6234
Mailing Address - Fax:
Practice Address - Street 1:111 WADSWORTH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-6102
Practice Address - Country:US
Practice Address - Phone:212-740-7400
Practice Address - Fax:212-740-7408
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041143225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist