Provider Demographics
NPI:1023304995
Name:INNOVATIVE PEDIATRIC THERAPIES PT OT SLP PLLC
Entity type:Organization
Organization Name:INNOVATIVE PEDIATRIC THERAPIES PT OT SLP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISE
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRICONE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, PCS
Authorized Official - Phone:845-353-3331
Mailing Address - Street 1:31 BURD STREET
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960
Mailing Address - Country:US
Mailing Address - Phone:845-353-3331
Mailing Address - Fax:
Practice Address - Street 1:31 BURD ST
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-3205
Practice Address - Country:US
Practice Address - Phone:845-353-3331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-20
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003760-1261QH0700X
NY005413-1261QR0400X
NY009027-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation