Provider Demographics
NPI:1376148767
Name:BACTOL, HALLEY MARK BEJO
Entity Type:Individual
Prefix:
First Name:HALLEY MARK
Middle Name:BEJO
Last Name:BACTOL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6117 183RD ST FL 2ND
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2114
Mailing Address - Country:US
Mailing Address - Phone:458-225-0179
Mailing Address - Fax:
Practice Address - Street 1:229 E 21ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-6433
Practice Address - Country:US
Practice Address - Phone:212-473-3703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist