Healthcare Provider Details

I. General information

NPI: 1982990743
Provider Name (Legal Business Name): ST JUDE'S PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2011
Last Update Date: 11/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7712 4TH AVE # 1
BROOKLYN NY
11209-3402
US

IV. Provider business mailing address

212 MACON ST 2ND FLOOR
BROOKLYN NY
11216-2405
US

V. Phone/Fax

Practice location:
  • Phone: 646-224-8040
  • Fax:
Mailing address:
  • Phone: 347-524-0630
  • Fax: 646-224-8040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number016896-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number020555-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number028641
License Number StateNY

VIII. Authorized Official

Name: DR. KEISHA E JOHN
Title or Position: CO-PRESIDENT
Credential: DPT
Phone: 347-524-0630