Provider Demographics
NPI:1881990935
Name:LIFESPAN PT OT &SLP SERVICES PLLC
Entity type:Organization
Organization Name:LIFESPAN PT OT &SLP SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MANDEL
Authorized Official - Suffix:
Authorized Official - Credentials:PT, PCS
Authorized Official - Phone:315-364-7570
Mailing Address - Street 1:8842 STATE ROUTE 90 N
Mailing Address - Street 2:
Mailing Address - City:KING FERRY
Mailing Address - State:NY
Mailing Address - Zip Code:13081-8717
Mailing Address - Country:US
Mailing Address - Phone:315-364-7570
Mailing Address - Fax:315-364-8016
Practice Address - Street 1:8842 STATE ROUTE 90 N
Practice Address - Street 2:
Practice Address - City:KING FERRY
Practice Address - State:NY
Practice Address - Zip Code:13081-8717
Practice Address - Country:US
Practice Address - Phone:315-364-7570
Practice Address - Fax:315-364-8016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119347-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty