Provider Demographics
NPI:1477657591
Name:BECKER, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BECKER
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 1:2827 ROUTE 9
Mailing Address - Street 2:P.O. BOX 187
Mailing Address - City:VALATIE
Mailing Address - State:NY
Mailing Address - Zip Code:12184
Mailing Address - Country:US
Mailing Address - Phone:518-758-7616
Mailing Address - Fax:
Practice Address - Street 1:2827 ROUTE 9
Practice Address - Street 2:GRAND UNION PLAZA
Practice Address - City:VALATIE
Practice Address - State:NY
Practice Address - Zip Code:12184
Practice Address - Country:US
Practice Address - Phone:518-758-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024764225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02354896Medicaid
NYQQ5871Medicare ID - Type Unspecified
NY02354896Medicaid