Provider Demographics
NPI:1689864472
Name:INTEGRATIVE SPORTS PHYSICAL THERAPY
Entity Type:Organization
Organization Name:INTEGRATIVE SPORTS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WOJCIECH
Authorized Official - Middle Name:
Authorized Official - Last Name:TELACKI
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:516-365-8215
Mailing Address - Street 1:1025 NORTHERN BOULVARD
Mailing Address - Street 2:SUITE 93
Mailing Address - City:ROSLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11576
Mailing Address - Country:US
Mailing Address - Phone:516-365-8215
Mailing Address - Fax:516-365-8296
Practice Address - Street 1:1025 NORTHERN BOULVARD
Practice Address - Street 2:SUITE 93
Practice Address - City:ROSLYN
Practice Address - State:NY
Practice Address - Zip Code:11576
Practice Address - Country:US
Practice Address - Phone:516-365-8215
Practice Address - Fax:516-365-8296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022886225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty