Provider Demographics
NPI:1780854075
Name:SHIN, EUNSEONG (PT)
Entity Type:Individual
Prefix:MISS
First Name:EUNSEONG
Middle Name:
Last Name:SHIN
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 1:14720 35TH AVE APT 12B
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-3774
Mailing Address - Country:US
Mailing Address - Phone:917-797-8512
Mailing Address - Fax:
Practice Address - Street 1:13618 35TH AVE # 1B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-2943
Practice Address - Country:US
Practice Address - Phone:917-797-8512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-03
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020751225100000X
NJ40QA01207600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist