Provider Demographics
NPI:1841334398
Name:GAETA, GLYNNIS RAE (PT)
Entity type:Individual
Prefix:
First Name:GLYNNIS
Middle Name:RAE
Last Name:GAETA
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 1:22 WICHARD DR
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1548
Mailing Address - Country:US
Mailing Address - Phone:631-838-0482
Mailing Address - Fax:
Practice Address - Street 1:22 WICHARD DR
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:NY
Practice Address - Zip Code:11769-1548
Practice Address - Country:US
Practice Address - Phone:631-838-0482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist