Healthcare Provider Details

I. General information

NPI: 1568482776
Provider Name (Legal Business Name): AUSTIN PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 08/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 STEWART AVE.
ROSCOE NY
12776
US

IV. Provider business mailing address

PO BOX 157
ROSCOE NY
12776-0157
US

V. Phone/Fax

Practice location:
  • Phone: 607-498-5653
  • Fax: 607-498-5671
Mailing address:
  • Phone: 607-498-5653
  • Fax: 607-498-5671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number0050371
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number005037-1
License Number StateNY

VIII. Authorized Official

Name: MRS. MARY JOHNSTON AUSTIN
Title or Position: OWNER
Credential: DPT
Phone: 607-498-5653