Provider Demographics
NPI:1134964596
Name:KOMMUGURI, LYDIA REBEKAH (PT)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:REBEKAH
Last Name:KOMMUGURI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 43RD ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-6166
Mailing Address - Country:US
Mailing Address - Phone:469-449-2935
Mailing Address - Fax:
Practice Address - Street 1:887 E NEW YORK AVE STE A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1309
Practice Address - Country:US
Practice Address - Phone:718-221-1022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist