Provider Demographics
NPI:1093930554
Name:LEI-RIVERA, LAURA (PT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:
Last Name:LEI-RIVERA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 MIDDLE LOOP RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10308-1922
Mailing Address - Country:US
Mailing Address - Phone:917-690-7463
Mailing Address - Fax:
Practice Address - Street 1:310 E 14TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-4201
Practice Address - Country:US
Practice Address - Phone:212-979-4673
Practice Address - Fax:212-533-4371
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016925-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist