Provider Demographics
NPI:1093876054
Name:BALDWIN HARBOR PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BALDWIN HARBOR PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATIS CICIO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:516-867-5050
Mailing Address - Street 1:830 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4098
Mailing Address - Country:US
Mailing Address - Phone:516-867-5050
Mailing Address - Fax:516-867-0868
Practice Address - Street 1:830 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-4098
Practice Address - Country:US
Practice Address - Phone:516-867-5050
Practice Address - Fax:516-867-0868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8972225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty