Provider Demographics
NPI:1700545803
Name:CREATIVE PHYSICAL THERAPY CARE PLLC
Entity Type:Organization
Organization Name:CREATIVE PHYSICAL THERAPY CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:WADEAA
Authorized Official - Middle Name:EDWAR MINA
Authorized Official - Last Name:IBRAHIMM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:646-415-2448
Mailing Address - Street 1:542 WESTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY COTTAGE
Mailing Address - State:NY
Mailing Address - Zip Code:10989-1320
Mailing Address - Country:US
Mailing Address - Phone:646-415-2448
Mailing Address - Fax:
Practice Address - Street 1:542 WESTFIELD DR
Practice Address - Street 2:
Practice Address - City:VALLEY COTTAGE
Practice Address - State:NY
Practice Address - Zip Code:10989-1320
Practice Address - Country:US
Practice Address - Phone:646-415-2448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty