Provider Demographics
NPI:1609339795
Name:FEIN, DEREK (PTA)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:FEIN
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 1:47 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-4325
Mailing Address - Country:US
Mailing Address - Phone:631-294-8663
Mailing Address - Fax:
Practice Address - Street 1:47 CHERRY ST
Practice Address - Street 2:
Practice Address - City:LAKE RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-4325
Practice Address - Country:US
Practice Address - Phone:631-294-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010454225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant