Healthcare Provider Details

I. General information

NPI: 1659413532
Provider Name (Legal Business Name): GRACE R MATOS-BRENNEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACE R MATOS

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227-7 MONTAUK HIGHWAY
OAKDALE NY
11769
US

IV. Provider business mailing address

PO BOX 726
STONY BROOK NY
11790-0726
US

V. Phone/Fax

Practice location:
  • Phone: 631-218-1545
  • Fax:
Mailing address:
  • Phone: 631-474-3652
  • Fax: 631-474-7893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number5729
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: