Healthcare Provider Details

I. General information

NPI: 1225607492
Provider Name (Legal Business Name): RUTUJA RAMESH MAHALE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 NORTHWEST DR
FARMINGDALE NY
11735-4935
US

IV. Provider business mailing address

475 NORTHERN BLVD STE 27
GREAT NECK NY
11021-4802
US

V. Phone/Fax

Practice location:
  • Phone: 516-420-2900
  • Fax: 516-420-2908
Mailing address:
  • Phone: 516-829-0030
  • Fax: 516-466-7723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number012713
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: