Provider Demographics
NPI:1588008833
Name:GONG, TERESA M (DPT)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:GONG
Suffix:
Gender:F
Credentials:DPT
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Other - First Name:
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Mailing Address - Street 1:8 CENTURY HILL DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2193
Mailing Address - Country:US
Mailing Address - Phone:518-690-4406
Mailing Address - Fax:518-220-9220
Practice Address - Street 1:8 CENTURY HILL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2193
Practice Address - Country:US
Practice Address - Phone:518-690-4406
Practice Address - Fax:518-220-9220
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2013-09-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY036484-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist