Provider Demographics
NPI:1457904468
Name:MODY, ISHA (PT)
Entity Type:Individual
Prefix:MS
First Name:ISHA
Middle Name:
Last Name:MODY
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 1:1163 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2408
Mailing Address - Country:US
Mailing Address - Phone:718-727-0055
Mailing Address - Fax:
Practice Address - Street 1:1163 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2408
Practice Address - Country:US
Practice Address - Phone:718-727-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2021-07-08
Deactivation Date:2020-09-24
Deactivation Code:
Reactivation Date:2021-07-08
Provider Licenses
StateLicense IDTaxonomies
NY043336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist