Healthcare Provider Details

I. General information

NPI: 1962533513
Provider Name (Legal Business Name): KYOKO IJICHI PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W 25TH ST SUITE 507
NEW YORK NY
10011-5561
US

IV. Provider business mailing address

511 W 25TH ST SUITE 507
NEW YORK NY
10001-5561
US

V. Phone/Fax

Practice location:
  • Phone: 212-741-5544
  • Fax:
Mailing address:
  • Phone: 212-741-5544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number520067-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number027038-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01164900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: