Provider Demographics
NPI:1023629714
Name:HERBLIN-WYNN, SIGRID MARCELLE (PTA)
Entity type:Individual
Prefix:MS
First Name:SIGRID
Middle Name:MARCELLE
Last Name:HERBLIN-WYNN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CARMANS RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-1438
Mailing Address - Country:US
Mailing Address - Phone:516-608-6200
Mailing Address - Fax:
Practice Address - Street 1:1 CARMANS RD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA PARK
Practice Address - State:NY
Practice Address - Zip Code:11762-1438
Practice Address - Country:US
Practice Address - Phone:516-608-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004667-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty