Provider Demographics
NPI:1104861608
Name:GANTMAN, YEVGENIYA (PT)
Entity Type:Individual
Prefix:
First Name:YEVGENIYA
Middle Name:
Last Name:GANTMAN
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 1:155 OCEANA DRIVE EAST
Mailing Address - Street 2:6B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6685
Mailing Address - Country:US
Mailing Address - Phone:718-266-3399
Mailing Address - Fax:718-266-2773
Practice Address - Street 1:155 OCEANA DR E
Practice Address - Street 2:6B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6684
Practice Address - Country:US
Practice Address - Phone:718-578-7427
Practice Address - Fax:718-975-2711
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02153244Medicaid
NY02153244Medicaid
NYQL5971Medicare ID - Type Unspecified