Provider Demographics
NPI:1013517788
Name:MAILLOUX, NATHANIEL MARK (PT)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:MARK
Last Name:MAILLOUX
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6435
Mailing Address - Country:US
Mailing Address - Phone:603-716-6530
Mailing Address - Fax:
Practice Address - Street 1:65 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6435
Practice Address - Country:US
Practice Address - Phone:603-716-6530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046438225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist