Provider Demographics
NPI:1083369920
Name:REDUBLO, RENEE ANN JAVIER
Entity Type:Individual
Prefix:
First Name:RENEE ANN
Middle Name:JAVIER
Last Name:REDUBLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5732 HOFFMAN DR APT 3
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4979
Mailing Address - Country:US
Mailing Address - Phone:747-474-9152
Mailing Address - Fax:
Practice Address - Street 1:1345 AVENUE OF THE AMERICAS FL 11
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10105-0013
Practice Address - Country:US
Practice Address - Phone:212-981-1977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-18
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011372225200000X
NY041248225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant