Provider Demographics
NPI:1083053037
Name:MAHAYAG, GRACE SALARDA (PT)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:SALARDA
Last Name:MAHAYAG
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 1:13715 70TH RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1929
Mailing Address - Country:US
Mailing Address - Phone:347-885-8950
Mailing Address - Fax:
Practice Address - Street 1:13411 KEW GARDENS RD
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1930
Practice Address - Country:US
Practice Address - Phone:347-875-1617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036344174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist