Provider Demographics
NPI:1558781914
Name:METTA PHYSICAL THERAPY, PLLC
Entity Type:Organization
Organization Name:METTA PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODILYNN
Authorized Official - Middle Name:DORA
Authorized Official - Last Name:LAWLISS-CORRADO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:518-658-9005
Mailing Address - Street 1:PO BOX 20
Mailing Address - Street 2:
Mailing Address - City:CHERRY PLAIN
Mailing Address - State:NY
Mailing Address - Zip Code:12040-0020
Mailing Address - Country:US
Mailing Address - Phone:518-658-9005
Mailing Address - Fax:518-658-9005
Practice Address - Street 1:17438 NY RT. 22
Practice Address - Street 2:
Practice Address - City:CHERRY PLAIN
Practice Address - State:NY
Practice Address - Zip Code:12040-0020
Practice Address - Country:US
Practice Address - Phone:518-658-9005
Practice Address - Fax:518-658-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012230-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1144431388OtherPERSONAL NPI