Provider Demographics
NPI:1457493017
Name:FACKELMAN, ZOE (PT)
Entity Type:Individual
Prefix:MS
First Name:ZOE
Middle Name:
Last Name:FACKELMAN
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 1:241 PARRISH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-1727
Mailing Address - Country:US
Mailing Address - Phone:585-396-1400
Mailing Address - Fax:585-396-3368
Practice Address - Street 1:241 PARRISH ST
Practice Address - Street 2:SUITE A
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1727
Practice Address - Country:US
Practice Address - Phone:585-396-1400
Practice Address - Fax:585-396-3368
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007432-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY145555FTOtherPREFERRED CARE PROVIDER I
NY1608653Medicaid
NY7997422OtherRCIPPAE PROVIDER ID
NY7997422OtherRCIPPAE PROVIDER ID
NYCC3482Medicare ID - Type UnspecifiedMEDICARE ID