Provider Demographics
NPI:1891902581
Name:GUERCIN, DOMINIQUE (PTA)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:GUERCIN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8402 AVENUE K
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4236
Mailing Address - Country:US
Mailing Address - Phone:718-209-9713
Mailing Address - Fax:
Practice Address - Street 1:121 DEKALB AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5425
Practice Address - Country:US
Practice Address - Phone:718-250-8142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001639-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant