Provider Demographics
NPI:1689661092
Name:SOUTHWICK, DOROTHEA BURGET (PT)
Entity Type:Individual
Prefix:MS
First Name:DOROTHEA
Middle Name:BURGET
Last Name:SOUTHWICK
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:PO BOX 702
Mailing Address - Street 2:
Mailing Address - City:CHAMPLAIN
Mailing Address - State:NY
Mailing Address - Zip Code:12919
Mailing Address - Country:US
Mailing Address - Phone:518-298-1111
Mailing Address - Fax:518-298-1111
Practice Address - Street 1:34 BEEMAN WAY
Practice Address - Street 2:
Practice Address - City:CHAMPLAIN
Practice Address - State:NY
Practice Address - Zip Code:12919
Practice Address - Country:US
Practice Address - Phone:518-298-1111
Practice Address - Fax:518-298-1111
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0065281225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000405998001OtherBLUE SHIELD OF NORTHEASTE
NYQ66832OtherEMPIRE BCBS
110409700OtherUS DEPT OF LABOR OWCP
NYQ66831OtherEMPIRE BLUE CROSS/EMPIRE
NY141733498OtherEMPIRE STATE PLAN GROUP
NYGRP405998002OtherBLUE SHIELD OF NORTHEASTE
650005243OtherRAILROAD MEDICARE
NY819687OtherEMPIRE STATE PLAN
NY141733498OtherEXCELLUS BLUE CROSS BLUE
NYP01010652OtherEXCELLUS
NYQ66832OtherEMPIRE BCBS
NYGRP405998002OtherBLUE SHIELD OF NORTHEASTE
NYQ66831OtherEMPIRE BLUE CROSS/EMPIRE