Healthcare Provider Details

I. General information

NPI: 1689608234
Provider Name (Legal Business Name): KAREN LINCOLN CONZO MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/21/2022
Certification Date: 01/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 CHURCH RD
GREAT RIVER NY
11739-3023
US

IV. Provider business mailing address

PO BOX 799
GREAT RIVER NY
11739-0799
US

V. Phone/Fax

Practice location:
  • Phone: 631-921-1277
  • Fax:
Mailing address:
  • Phone: 631-921-1277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number018199-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: