Provider Demographics
NPI:1831126234
Name:DESALVATORE, COLLEEN M (OT, PTA)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:DESALVATORE
Suffix:
Gender:F
Credentials:OT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:NY
Mailing Address - Zip Code:13021-1811
Mailing Address - Country:US
Mailing Address - Phone:315-255-2746
Mailing Address - Fax:315-255-2740
Practice Address - Street 1:182 NORTH ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1811
Practice Address - Country:US
Practice Address - Phone:315-255-2746
Practice Address - Fax:315-255-2740
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001987-1225200000X
NY012747-1225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA4585Medicare ID - Type UnspecifiedMEDICARE B
NYQ24954Medicare UPIN