Healthcare Provider Details

I. General information

NPI: 1154575074
Provider Name (Legal Business Name): MICHAEL SCOTTODIMASO AND TARA DEROSA, PT, OT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 JOHN ST STE 3
BABYLON NY
11702-2928
US

IV. Provider business mailing address

51 JOHN ST STE 3
BABYLON NY
11702-2928
US

V. Phone/Fax

Practice location:
  • Phone: 631-669-0333
  • Fax: 631-669-2436
Mailing address:
  • Phone: 631-669-0333
  • Fax: 631-669-2436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0129451
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL SCOTTODIMASO
Title or Position: OWNER
Credential: PT
Phone: 631-669-0333