Provider Demographics
NPI:1356055024
Name:GALLEGOS, MARISSA NARTATES
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:NARTATES
Last Name:GALLEGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3620
Mailing Address - Country:US
Mailing Address - Phone:201-492-2813
Mailing Address - Fax:
Practice Address - Street 1:1110 2ND AVE RM 302
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-2021
Practice Address - Country:US
Practice Address - Phone:212-842-0080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049593-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist