Provider Demographics
NPI:1093084634
Name:PROGRESSIVE REHAB AND HOME CARE PT & OT, PLLC
Entity Type:Organization
Organization Name:PROGRESSIVE REHAB AND HOME CARE PT & OT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAHROS
Authorized Official - Middle Name:K
Authorized Official - Last Name:ISAAC
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:201-803-7008
Mailing Address - Street 1:537 BANTA ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-1918
Mailing Address - Country:US
Mailing Address - Phone:201-803-7008
Mailing Address - Fax:201-786-9222
Practice Address - Street 1:537 BANTA ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-1918
Practice Address - Country:US
Practice Address - Phone:201-803-7008
Practice Address - Fax:201-786-9222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-28
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023107225100000X
NY014057225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100063486Medicare PIN