Healthcare Provider Details

I. General information

NPI: 1346387313
Provider Name (Legal Business Name): TANYA M. NEILSEN PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 UNION BLVD
WEST ISLIP NY
11795-3105
US

IV. Provider business mailing address

1007 OLD MEDFORD AVE
FARMINGVILLE NY
11738-2829
US

V. Phone/Fax

Practice location:
  • Phone: 631-376-4109
  • Fax:
Mailing address:
  • Phone: 631-236-5784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number023990-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: