Provider Demographics
NPI:1790330355
Name:TSEVDOS, CODY
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:TSEVDOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 BROADHOLLOW ROAD
Mailing Address - Street 2:SUITE PRO EX
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747
Mailing Address - Country:US
Mailing Address - Phone:631-359-5859
Mailing Address - Fax:
Practice Address - Street 1:1150 HALL OF FAME AVE STE 3
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2532
Practice Address - Country:US
Practice Address - Phone:413-241-8900
Practice Address - Fax:413-241-8901
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA24336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist