Provider Demographics
NPI:1750527784
Name:THREE PEAKS PHYSICAL THERAPY
Entity type:Organization
Organization Name:THREE PEAKS PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SHEPPARD
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:631-226-2918
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-0607
Mailing Address - Country:US
Mailing Address - Phone:631-226-2918
Mailing Address - Fax:631-226-2746
Practice Address - Street 1:375 MAIN ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751-3542
Practice Address - Country:US
Practice Address - Phone:631-226-2918
Practice Address - Fax:631-226-2746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032701225100000X
NY029690225100000X
CO3322225100000X
NY013122225700000X
NY008590225700000X
CO10424225700000X
NY016755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty