Healthcare Provider Details

I. General information

NPI: 1114833704
Provider Name (Legal Business Name): FABIOLA CAICEDO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 W MERRICK RD
VALLEY STREAM NY
11580-5511
US

IV. Provider business mailing address

21229 HILLSIDE AVE APT 5EE
QUEENS VILLAGE NY
11427-1847
US

V. Phone/Fax

Practice location:
  • Phone: 516-423-4652
  • Fax:
Mailing address:
  • Phone: 347-256-7559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number009732-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: