Provider Demographics
NPI:1396022752
Name:PROTHERAPY REHABILITATION OT, PT, SLP, PLLC
Entity Type:Organization
Organization Name:PROTHERAPY REHABILITATION OT, PT, SLP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RUSSALETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAGBANUA
Authorized Official - Suffix:
Authorized Official - Credentials:MPS, OTR/L, CHT
Authorized Official - Phone:917-459-3695
Mailing Address - Street 1:866 E TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10460-4201
Mailing Address - Country:US
Mailing Address - Phone:718-589-2200
Mailing Address - Fax:
Practice Address - Street 1:866 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10460-4201
Practice Address - Country:US
Practice Address - Phone:718-589-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-12
Last Update Date:2011-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012509261QH0700X
NY022020261QP2000X
NY010144261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy