Provider Demographics
NPI:1790144178
Name:LEARY, IAN (ATC)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:LEARY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 COTTAGE BVLD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801
Mailing Address - Country:US
Mailing Address - Phone:516-729-3357
Mailing Address - Fax:
Practice Address - Street 1:1300 FRANKLIN AVE
Practice Address - Street 2:SUITE LL2
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-1886
Practice Address - Country:US
Practice Address - Phone:516-663-9099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-15
Last Update Date:2016-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0030242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer