Provider Demographics
NPI:1417306507
Name:BAENA, JASPER RAYMOND TOLENTINO (PT)
Entity Type:Individual
Prefix:
First Name:JASPER RAYMOND
Middle Name:TOLENTINO
Last Name:BAENA
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 1:7 DANICA WAY
Mailing Address - Street 2:UNIT 23
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-3360
Mailing Address - Country:US
Mailing Address - Phone:213-712-6052
Mailing Address - Fax:
Practice Address - Street 1:641 OLD ROUTE 17
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-7014
Practice Address - Country:US
Practice Address - Phone:845-794-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY39421-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics