Healthcare Provider Details

I. General information

NPI: 1457505513
Provider Name (Legal Business Name): MICHELE JO PETHERICK P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2008
Last Update Date: 08/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 FRANKLIN AVE LL2
GARDEN CITY NY
11530-5747
US

IV. Provider business mailing address

1300 FRANKLIN AVE LL2
GARDEN CITY NY
11530-5747
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-9099
  • Fax: 516-663-9092
Mailing address:
  • Phone: 516-663-9099
  • Fax: 516-663-9092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number010022-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number010022-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number010022-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number010022-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: