Provider Demographics
NPI:1023033289
Name:HWANG, THERESA JAEHEE (DPT)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:JAEHEE
Last Name:HWANG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:JAEHEE
Other - Last Name:FOWLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1075 CENTRAL PARK AVE STE 407
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-3232
Mailing Address - Country:US
Mailing Address - Phone:914-214-9220
Mailing Address - Fax:
Practice Address - Street 1:1075 CENTRAL PARK AVE STE 407
Practice Address - Street 2:
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-3232
Practice Address - Country:US
Practice Address - Phone:914-214-9220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022048225100000X
2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05238555Medicaid