Healthcare Provider Details

I. General information

NPI: 1730692534
Provider Name (Legal Business Name): EMILY RUTH CHADWICK ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 TERRACE CIR APT 1C
GREAT NECK NY
11021-4187
US

IV. Provider business mailing address

30 TERRACE CIR APT 1C
GREAT NECK NY
11021-4187
US

V. Phone/Fax

Practice location:
  • Phone: 603-491-8065
  • Fax:
Mailing address:
  • Phone: 603-491-8065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number003135
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: