Provider Demographics
NPI:1407152622
Name:HARSONO, TATI B (PT)
Entity Type:Individual
Prefix:
First Name:TATI
Middle Name:B
Last Name:HARSONO
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 1:384 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-5112
Mailing Address - Country:US
Mailing Address - Phone:347-424-9686
Mailing Address - Fax:646-861-5926
Practice Address - Street 1:500 BI COUNTY BLVD
Practice Address - Street 2:SUITE 210N
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735-3988
Practice Address - Country:US
Practice Address - Phone:718-264-1640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-04
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021060-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist