Provider Demographics
NPI:1710605811
Name:THERAYOUTH FOUNDATION
Entity Type:Organization
Organization Name:THERAYOUTH FOUNDATION
Other - Org Name:THERAYOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCOFF
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:516-770-2055
Mailing Address - Street 1:571 CENTRAL AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-1547
Mailing Address - Country:US
Mailing Address - Phone:516-770-2055
Mailing Address - Fax:
Practice Address - Street 1:571 CENTRAL AVE STE 106
Practice Address - Street 2:
Practice Address - City:NEW PROVIDENCE
Practice Address - State:NJ
Practice Address - Zip Code:07974-1547
Practice Address - Country:US
Practice Address - Phone:516-770-2055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-16
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty