Healthcare Provider Details

I. General information

NPI: 1023546207
Provider Name (Legal Business Name): GROWING UP PHYSICAL THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 CAPRICORN LN
MONSEY NY
10952-5112
US

IV. Provider business mailing address

38 CAPRICORN LN
MONSEY NY
10952-5112
US

V. Phone/Fax

Practice location:
  • Phone: 917-582-4396
  • Fax: 845-694-8903
Mailing address:
  • Phone: 917-582-4396
  • Fax: 845-694-8903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number023141
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number023141
License Number StateNY

VIII. Authorized Official

Name: MELINDA ANNE DE LEON
Title or Position: PHYSICAL THERAPIST
Credential: PT, DPT
Phone: 917-582-4396