Provider Demographics
NPI:1134221799
Name:HAASE, GRETCHEN ELIZABETH (DPT)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:ELIZABETH
Last Name:HAASE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1210 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2176
Mailing Address - Country:US
Mailing Address - Phone:631-567-8144
Mailing Address - Fax:631-567-8144
Practice Address - Street 1:5380 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2056
Practice Address - Country:US
Practice Address - Phone:631-474-4096
Practice Address - Fax:631-474-5299
Is Sole Proprietor?:No
Enumeration Date:2006-09-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024126-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQP2771Medicare ID - Type Unspecified