Provider Demographics
NPI:1154323624
Name:ETTENSON, GABRIEL D (PT)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:D
Last Name:ETTENSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:151 LOCUST LANE
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:10533
Mailing Address - Country:US
Mailing Address - Phone:516-967-8108
Mailing Address - Fax:
Practice Address - Street 1:1365 YORK AVE
Practice Address - Street 2:SUITE P2
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4035
Practice Address - Country:US
Practice Address - Phone:212-472-5820
Practice Address - Fax:212-472-5821
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018762225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ5WDF1Medicare ID - Type UnspecifiedEQUILIBRIUM PT
NYQ14T71Medicare ID - Type UnspecifiedPHYSICAL THERAPIST