Healthcare Provider Details

I. General information

NPI: 1124215512
Provider Name (Legal Business Name): COURTNEY L SMALLEY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 09/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 5TH AVE SUITE 5115
NEW YORK NY
10118-0110
US

IV. Provider business mailing address

1230 WOODYCREST AVE APT 2C
BRONX NY
10452-3729
US

V. Phone/Fax

Practice location:
  • Phone: 866-601-6474
  • Fax: 212-928-9545
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number006597-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: