Provider Demographics
NPI:1104083013
Name:FAVRET, ERIN L (PTA)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:L
Last Name:FAVRET
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:L
Other - Last Name:LALONDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11050 MT BELVEDERE BLVD
Mailing Address - Street 2:USA MEDDAC ATTN CREDENTIALS
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-772-4025
Mailing Address - Fax:315-772-9498
Practice Address - Street 1:11050 MT BELVEDERE BLVD
Practice Address - Street 2:USA MEDDAC/CREDENTIALS
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:315-772-4025
Practice Address - Fax:315-772-9498
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006333225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN