Provider Demographics
NPI:1578694279
Name:GANUN, COLLEEN MARY (PT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARY
Last Name:GANUN
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 1:2060 BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11509-1107
Mailing Address - Country:US
Mailing Address - Phone:516-972-7766
Mailing Address - Fax:
Practice Address - Street 1:196 BIRCH HILL RD
Practice Address - Street 2:
Practice Address - City:LOCUST VALLEY
Practice Address - State:NY
Practice Address - Zip Code:11560-1832
Practice Address - Country:US
Practice Address - Phone:516-759-9717
Practice Address - Fax:516-759-1666
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027412225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist