Provider Demographics
NPI:1720114895
Name:ARESTIVO, AUDRA LYNN (PT)
Entity Type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:LYNN
Last Name:ARESTIVO
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 1:18 SHEFFIELD LN
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3248
Mailing Address - Country:US
Mailing Address - Phone:631-757-0948
Mailing Address - Fax:631-757-0948
Practice Address - Street 1:18 SHEFFIELD LN
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-3248
Practice Address - Country:US
Practice Address - Phone:631-757-0948
Practice Address - Fax:631-757-0948
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011208-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist