Healthcare Provider Details

I. General information

NPI: 1659351526
Provider Name (Legal Business Name): VICTORIA BOSSOREALE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 MARK TREE RD
CENTEREACH NY
11720-2221
US

IV. Provider business mailing address

55 MAPLEWOOD AVE
SELDEN NY
11784-3013
US

V. Phone/Fax

Practice location:
  • Phone: 631-467-4235
  • Fax: 631-467-2655
Mailing address:
  • Phone: 631-467-4235
  • Fax: 631-467-2655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number012259-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: