Healthcare Provider Details

I. General information

NPI: 1477248813
Provider Name (Legal Business Name): PROFESSIONAL OCCUPATIONAL & PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 RONALD REAGAN BLVD
WARWICK NY
10990-4105
US

IV. Provider business mailing address

576 BROADHOLLOW RD
MELVILLE NY
11747-5002
US

V. Phone/Fax

Practice location:
  • Phone: 845-328-8967
  • Fax: 845-228-8064
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN BRUSH
Title or Position: MANAGER OF CREDENTIALING
Credential:
Phone: 631-359-5859