Provider Demographics
NPI:1407181324
Name:CHARLEBOIS, DANIEL R (PT)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:R
Last Name:CHARLEBOIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MANOR PL
Mailing Address - Street 2:
Mailing Address - City:GREENPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11944-1222
Mailing Address - Country:US
Mailing Address - Phone:631-765-9389
Mailing Address - Fax:631-765-9369
Practice Address - Street 1:46520 NORTH RD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-5040
Practice Address - Country:US
Practice Address - Phone:631-765-9389
Practice Address - Fax:631-765-9369
Is Sole Proprietor?:No
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4399225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00274337Medicaid
NY330088Medicare UPIN