Provider Demographics
NPI:1255473849
Name:MODICA, CONNIE L (PT DPT MS)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:L
Last Name:MODICA
Suffix:
Gender:F
Credentials:PT DPT MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 HUMPHREY DR
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4022
Mailing Address - Country:US
Mailing Address - Phone:516-921-7171
Mailing Address - Fax:
Practice Address - Street 1:47 HUMPHREY DR
Practice Address - Street 2:
Practice Address - City:SYOSSET
Practice Address - State:NY
Practice Address - Zip Code:11791-4022
Practice Address - Country:US
Practice Address - Phone:516-921-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist