Provider Demographics
NPI:1295370682
Name:BAESA, OLIVIA THADANI (PT)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:THADANI
Last Name:BAESA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8635 QUEENS BLVD APT 1H
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-4408
Mailing Address - Country:US
Mailing Address - Phone:516-492-9896
Mailing Address - Fax:
Practice Address - Street 1:24519 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1414
Practice Address - Country:US
Practice Address - Phone:718-343-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-09
Last Update Date:2019-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039418225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist