Healthcare Provider Details

I. General information

NPI: 1457321911
Provider Name (Legal Business Name): STEVEN C DESOUSA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 LARKFIELD RD SUITE 207
EAST NORTHPORT NY
11731-4205
US

IV. Provider business mailing address

554 LARKFIELD RD SUITE 207
EAST NORTHPORT NY
11731-4205
US

V. Phone/Fax

Practice location:
  • Phone: 631-266-4501
  • Fax: 631-266-4502
Mailing address:
  • Phone: 631-266-4501
  • Fax: 631-266-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0138961
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number0138961
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number0138961
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number0138961
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: