Provider Demographics
NPI:1770550915
Name:GORNELL, JUSTIN B (DPT, OCS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:B
Last Name:GORNELL
Suffix:
Gender:M
Credentials:DPT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1556 3RD AVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-3100
Mailing Address - Country:US
Mailing Address - Phone:201-780-9691
Mailing Address - Fax:646-863-2650
Practice Address - Street 1:1556 3RD AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3100
Practice Address - Country:US
Practice Address - Phone:201-780-9691
Practice Address - Fax:646-863-2650
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYNY024310225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist