Provider Demographics
NPI:1295374320
Name:SAMARISTA, MARY KATHLEEN SABILE (PT)
Entity Type:Individual
Prefix:
First Name:MARY KATHLEEN
Middle Name:SABILE
Last Name:SAMARISTA
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 1:1150 PELHAM PKWY S APT 6C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-1032
Mailing Address - Country:US
Mailing Address - Phone:917-326-0103
Mailing Address - Fax:
Practice Address - Street 1:1072 HAVEMEYER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-5310
Practice Address - Country:US
Practice Address - Phone:718-863-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040070225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist