Provider Demographics
NPI:1932215712
Name:DE NIES, MARK HENRY (PT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HENRY
Last Name:DE NIES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 FERRIS LN
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-4106
Mailing Address - Country:US
Mailing Address - Phone:845-452-5758
Mailing Address - Fax:
Practice Address - Street 1:139 CORNELL ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3633
Practice Address - Country:US
Practice Address - Phone:845-338-1234
Practice Address - Fax:845-338-1234
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003305225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003305OtherLICENSE
NY00972876Medicaid
NY00972876Medicaid