Healthcare Provider Details

I. General information

NPI: 1053537407
Provider Name (Legal Business Name): SALEM SPORTS & SPINE PHYSICAL THEARPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 JUNE ROAD
NORTH SALEM NY
10560-0662
US

IV. Provider business mailing address

PO BOX 662
NORTH SALEM NY
10560-0662
US

V. Phone/Fax

Practice location:
  • Phone: 914-669-9085
  • Fax: 914-669-9095
Mailing address:
  • Phone: 914-669-9085
  • Fax: 914-669-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number018914-1
License Number StateNY

VIII. Authorized Official

Name: MS. MICHELE LYNN LEASURE
Title or Position: OWNER
Credential: P.T., OCS
Phone: 914-669-9085