Provider Demographics
NPI:1013636711
Name:SWICK, RAISELLE MOLLY
Entity Type:Individual
Prefix:
First Name:RAISELLE
Middle Name:MOLLY
Last Name:SWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:524 4TH AVE APT 3R
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4778
Mailing Address - Country:US
Mailing Address - Phone:860-460-8530
Mailing Address - Fax:
Practice Address - Street 1:263 7TH AVE STE 2A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3693
Practice Address - Country:US
Practice Address - Phone:718-369-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0491552251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic