Healthcare Provider Details

I. General information

NPI: 1891833497
Provider Name (Legal Business Name): SPRING LAKE PT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 WYANDOTTE AVE
HIGHLAND FALLS NY
10928-1311
US

IV. Provider business mailing address

1008 PINE VW
NEW WINDSOR NY
12553-4902
US

V. Phone/Fax

Practice location:
  • Phone: 845-446-4646
  • Fax:
Mailing address:
  • Phone: 845-458-4932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. TONI MARIA WANAMAKER
Title or Position: OFFICE COORDINATOR
Credential:
Phone: 845-458-4932