Provider Demographics
NPI:1902181266
Name:FULL CIRCLE PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:FULL CIRCLE PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TJADEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, ATC
Authorized Official - Phone:516-739-5503
Mailing Address - Street 1:397 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2208
Mailing Address - Country:US
Mailing Address - Phone:516-739-5503
Mailing Address - Fax:516-739-5565
Practice Address - Street 1:397 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2208
Practice Address - Country:US
Practice Address - Phone:516-739-5503
Practice Address - Fax:516-739-5565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025535-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty