Provider Demographics
NPI:1093853657
Name:THERAPEUTIC PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:THERAPEUTIC PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:MONTEFRIO
Authorized Official - Last Name:HISOLE CEBALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:BSPT
Authorized Official - Phone:631-839-4059
Mailing Address - Street 1:15 MONMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-2514
Mailing Address - Country:US
Mailing Address - Phone:631-839-4059
Mailing Address - Fax:631-254-0784
Practice Address - Street 1:1570 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5238
Practice Address - Country:US
Practice Address - Phone:516-338-0412
Practice Address - Fax:516-338-1106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019468225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty