Provider Demographics
NPI:1558829747
Name:CALIS, CLINT LOUIS JUANILLO (PTA)
Entity Type:Individual
Prefix:
First Name:CLINT LOUIS
Middle Name:JUANILLO
Last Name:CALIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 NOB HILL DR
Mailing Address - Street 2:
Mailing Address - City:ELMSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:10523-2420
Mailing Address - Country:US
Mailing Address - Phone:660-890-4432
Mailing Address - Fax:
Practice Address - Street 1:242 NOB HILL DR
Practice Address - Street 2:
Practice Address - City:ELMSFORD
Practice Address - State:NY
Practice Address - Zip Code:10523-2420
Practice Address - Country:US
Practice Address - Phone:660-890-4432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009298225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant