Provider Demographics
NPI:1669122842
Name:VICENTE, LOUIE SAMILEY (PTA)
Entity type:Individual
Prefix:MR
First Name:LOUIE
Middle Name:SAMILEY
Last Name:VICENTE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8523 BROADWAY APT 2D
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5863
Mailing Address - Country:US
Mailing Address - Phone:646-981-8163
Mailing Address - Fax:
Practice Address - Street 1:11045 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5501
Practice Address - Country:US
Practice Address - Phone:718-575-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-28
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008787-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant