Provider Demographics
NPI:1689608234
Name:CONZO, KAREN LINCOLN (MSPT)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:LINCOLN
Last Name:CONZO
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 799
Mailing Address - Street 2:
Mailing Address - City:GREAT RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11739-0799
Mailing Address - Country:US
Mailing Address - Phone:631-921-1277
Mailing Address - Fax:
Practice Address - Street 1:41 CHURCH RD
Practice Address - Street 2:
Practice Address - City:GREAT RIVER
Practice Address - State:NY
Practice Address - Zip Code:11739-3023
Practice Address - Country:US
Practice Address - Phone:631-921-1277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018199-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03494864Medicaid
NY0406498Medicaid
NY03494864Medicaid