Healthcare Provider Details

I. General information

NPI: 1225941917
Provider Name (Legal Business Name): JULIE DEMENTYEVA PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 E 149TH ST BLDG SUITE
BRONX NY
10451-5602
US

IV. Provider business mailing address

620 W 143RD ST APT 6H
NEW YORK NY
10031-5954
US

V. Phone/Fax

Practice location:
  • Phone: 718-928-6582
  • Fax:
Mailing address:
  • Phone: 951-566-6750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number015414
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: