Provider Demographics
NPI:1144742479
Name:PROVIDENT PHYSICAL AND OCCUPATIONAL THERAPY PLLC
Entity Type:Organization
Organization Name:PROVIDENT PHYSICAL AND OCCUPATIONAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DESOUSA
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, MA, OCS
Authorized Official - Phone:631-266-4501
Mailing Address - Street 1:554 LARKFIELD RD STE 207
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731-4205
Mailing Address - Country:US
Mailing Address - Phone:631-266-4501
Mailing Address - Fax:631-266-4502
Practice Address - Street 1:554 LARKFIELD RD STE 207
Practice Address - Street 2:
Practice Address - City:EAST NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11731-4205
Practice Address - Country:US
Practice Address - Phone:631-266-4501
Practice Address - Fax:631-266-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-07
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225100000X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty