Provider Demographics
NPI:1114968872
Name:POWERS, REGINA GRACE (PT,MS)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:GRACE
Last Name:POWERS
Suffix:
Gender:F
Credentials:PT,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2117
Mailing Address - Country:US
Mailing Address - Phone:631-444-5603
Mailing Address - Fax:631-444-5604
Practice Address - Street 1:128 OLD TOWN RD
Practice Address - Street 2:LOWER LEVEL @ SETAUKET OFFICE PARK
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2064
Practice Address - Country:US
Practice Address - Phone:631-444-5603
Practice Address - Fax:631-444-5604
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008596-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQP3471Medicare ID - Type Unspecified