Provider Demographics
NPI:1083800163
Name:COMMUNITY PHYSICAL THERAPY & WELLNESS PC
Entity Type:Organization
Organization Name:COMMUNITY PHYSICAL THERAPY & WELLNESS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALLAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-773-2300
Mailing Address - Street 1:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:GLOVERSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12078-0009
Mailing Address - Country:US
Mailing Address - Phone:518-773-2300
Mailing Address - Fax:518-773-2334
Practice Address - Street 1:41 ARTERIAL PLAZA
Practice Address - Street 2:SUITE 15B
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078
Practice Address - Country:US
Practice Address - Phone:518-773-2300
Practice Address - Fax:518-773-2334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017161-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02441963Medicaid
NY02441963Medicaid
NYY09021Medicare UPIN