Provider Demographics
NPI:1205010576
Name:YI, SEUNGYOUL (RPT)
Entity Type:Individual
Prefix:
First Name:SEUNGYOUL
Middle Name:
Last Name:YI
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:YI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RPT
Mailing Address - Street 1:232 BROAD AVE
Mailing Address - Street 2:FRNT 2A
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1577
Mailing Address - Country:US
Mailing Address - Phone:201-500-5571
Mailing Address - Fax:
Practice Address - Street 1:232 BROAD AVE
Practice Address - Street 2:FRNT 2A
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1577
Practice Address - Country:US
Practice Address - Phone:201-500-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-21
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01145000225100000X
NY024761225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist