Provider Demographics
NPI:1083873392
Name:BEHRENS, SUSAN NEEL GILLEENY (DPT)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:NEEL GILLEENY
Last Name:BEHRENS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:NEEL
Other - Last Name:GILLEENY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:26 FOREST LN
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-1117
Mailing Address - Country:US
Mailing Address - Phone:631-929-6189
Mailing Address - Fax:
Practice Address - Street 1:607 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-3345
Practice Address - Country:US
Practice Address - Phone:631-732-3900
Practice Address - Fax:631-732-3908
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030242225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist