Healthcare Provider Details

I. General information

NPI: 1346093762
Provider Name (Legal Business Name): COMFORT MODUPE UWADIAE PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 12/05/2024
Certification Date: 11/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 EVERIT AVE
HEWLETT NY
11557-1303
US

IV. Provider business mailing address

30 EVERIT AVE
HEWLETT NY
11557-1303
US

V. Phone/Fax

Practice location:
  • Phone: 347-731-9836
  • Fax:
Mailing address:
  • Phone: 347-731-9836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number035763-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: