Provider Demographics
NPI:1376919662
Name:DYNAMIC WELLNESS PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:DYNAMIC WELLNESS PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARYL LUISA
Authorized Official - Middle Name:TADABA
Authorized Official - Last Name:RASCO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:718-837-7581
Mailing Address - Street 1:7217 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-5634
Mailing Address - Country:US
Mailing Address - Phone:718-837-7581
Mailing Address - Fax:
Practice Address - Street 1:7217 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-5634
Practice Address - Country:US
Practice Address - Phone:718-837-7581
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031132225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04075590Medicaid