Provider Demographics
NPI:1053848028
Name:DE LA CRUZ, BRYAN JOSEPH GICANA (PT)
Entity Type:Individual
Prefix:
First Name:BRYAN JOSEPH
Middle Name:GICANA
Last Name:DE LA CRUZ
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5211 79TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4112
Mailing Address - Country:US
Mailing Address - Phone:848-667-0943
Mailing Address - Fax:
Practice Address - Street 1:865 CYPRESS AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-4724
Practice Address - Country:US
Practice Address - Phone:848-667-0943
Practice Address - Fax:848-667-0943
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist