Healthcare Provider Details

I. General information

NPI: 1760464069
Provider Name (Legal Business Name): HOWARD GUSTAV KREBAUM JR. PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 03/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 BELLEWOOD AVE
CENTEREACH NY
11720-1142
US

IV. Provider business mailing address

37 BELLWOOD AVE
CENTEREACH NY
11720-1142
US

V. Phone/Fax

Practice location:
  • Phone: 631-981-6021
  • Fax: 631-981-6021
Mailing address:
  • Phone: 631-981-6021
  • Fax: 631-981-6021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3782
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00122800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: