Provider Demographics
NPI:1023239605
Name:CHUKWUEKE, TONY (PTA)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:CHUKWUEKE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 WEST 18TH STREET
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036
Mailing Address - Country:US
Mailing Address - Phone:845-564-9853
Mailing Address - Fax:845-564-6974
Practice Address - Street 1:15 WEST 18TH STREET
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036
Practice Address - Country:US
Practice Address - Phone:845-564-9853
Practice Address - Fax:845-564-6974
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005317-1385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY005317-1OtherPTA LICENSE