Healthcare Provider Details

I. General information

NPI: 1508291212
Provider Name (Legal Business Name): GREEN LIGHT PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2761 BATH AVE BAS 1
BROOKLYN NY
11214-5551
US

IV. Provider business mailing address

2761 BATH AVE BAS 1
BROOKLYN NY
11214-5551
US

V. Phone/Fax

Practice location:
  • Phone: 718-872-7801
  • Fax: 718-872-7803
Mailing address:
  • Phone: 718-872-7801
  • Fax: 718-872-7803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number032199
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: STELLA DVORIN
Title or Position: PRESIDENT
Credential: DPT
Phone: 718-872-7801