Provider Demographics
NPI:1679583603
Name:WESTON PAXXON PT OT & SLP PLLC
Entity Type:Organization
Organization Name:WESTON PAXXON PT OT & SLP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:BERKLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:631-467-3700
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:610-991-2034
Mailing Address - Fax:610-438-2046
Practice Address - Street 1:345 NORTHERN BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1001
Practice Address - Country:US
Practice Address - Phone:518-462-1689
Practice Address - Fax:516-468-1689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022235-12251G0304X
NY013398-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0814Medicare PIN