Healthcare Provider Details

I. General information

NPI: 1790175115
Provider Name (Legal Business Name): MICHELE MODUGNO PT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2015
Last Update Date: 01/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ALBANY POST RD
MONTGOMERY NY
12549-2132
US

IV. Provider business mailing address

104 CARTWHEEL CT APT. 18
WASHINGTONVILLE NY
10992-2211
US

V. Phone/Fax

Practice location:
  • Phone: 845-457-3155
  • Fax: 845-457-4899
Mailing address:
  • Phone: 321-217-2780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number036325
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: