Healthcare Provider Details

I. General information

NPI: 1295732071
Provider Name (Legal Business Name): DENISE SEROTTA JACKSON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STEPHEN W. BASSIN, P.T., P.C. 32 SHERMAN AVE
GLEN FALLS NY
12801
US

IV. Provider business mailing address

STEPHEN W. BASSIN, P.T., P.C. 32 SHERMAN AVE
GLEN FALLS NY
12801
US

V. Phone/Fax

Practice location:
  • Phone: 518-793-7136
  • Fax: 518-793-7142
Mailing address:
  • Phone: 518-793-7136
  • Fax: 518-793-7142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number012831-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: