Provider Demographics
NPI:1457988115
Name:GEORGATOS, LEA (ATC)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:GEORGATOS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 HASBROUCK AVE
Mailing Address - Street 2:
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1162
Mailing Address - Country:US
Mailing Address - Phone:201-906-3927
Mailing Address - Fax:
Practice Address - Street 1:4513 MANHATTAN COLLEGE PKWY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10471-4004
Practice Address - Country:US
Practice Address - Phone:718-826-7226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-24
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT002695002255A2300X
NY0039352255A2300X
20000370082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003935OtherNEW YORK STATE EDUCATION DEPARTMENT - OFFICE OF THE PROFESSIONS
2000037008OtherBOARD OF CERTIFICATION
NJ25MT00269500OtherSTATE OF NEW JERSEY / NEW JERSEY DIVISION OF CONSUMER AFFAIRS