Healthcare Provider Details

I. General information

NPI: 1750192431
Provider Name (Legal Business Name): ETHAN HEALY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 07/11/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 8TH AVE STE 300
NEW YORK NY
10036-7000
US

IV. Provider business mailing address

258 DEKALB AVE APT 2
BROOKLYN NY
11205-3665
US

V. Phone/Fax

Practice location:
  • Phone: 212-245-1841
  • Fax:
Mailing address:
  • Phone: 901-692-4609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number053174-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: