Provider Demographics
NPI:1033280441
Name:GOTTESFELD, SUSAN B (PT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:B
Last Name:GOTTESFELD
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 1:1 SANDY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2521
Mailing Address - Country:US
Mailing Address - Phone:516-318-8546
Mailing Address - Fax:516-767-1181
Practice Address - Street 1:1 SANDY HOLLOW RD
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-2521
Practice Address - Country:US
Practice Address - Phone:516-318-8546
Practice Address - Fax:516-767-1181
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012180-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ88611Medicare ID - Type UnspecifiedPROVIDER ID