Provider Demographics
NPI:1396959540
Name:PANTALEO, MAUREEN BRADY (BAPT)
Entity type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:BRADY
Last Name:PANTALEO
Suffix:
Gender:F
Credentials:BAPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 DEER PARK AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-1314
Mailing Address - Country:US
Mailing Address - Phone:631-368-3792
Mailing Address - Fax:631-587-0979
Practice Address - Street 1:661 DEER PARK AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-1314
Practice Address - Country:US
Practice Address - Phone:631-368-3792
Practice Address - Fax:631-587-0979
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007630-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY815705OtherMPN PROVIDER NUMBER