Provider Demographics
NPI:1699008094
Name:CORSO, KEVIN (PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CORSO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5914
Mailing Address - Country:US
Mailing Address - Phone:201-488-0488
Mailing Address - Fax:201-224-6381
Practice Address - Street 1:1355 15TH ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-2039
Practice Address - Country:US
Practice Address - Phone:201-224-8717
Practice Address - Fax:201-224-6381
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01329700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist