Healthcare Provider Details

I. General information

NPI: 1821547357
Provider Name (Legal Business Name): MANITHA HEGDE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2016
Last Update Date: 09/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 LIPTON LN
WILLISTON PARK NY
11596-1029
US

IV. Provider business mailing address

60 LIPTON LN
WILLISTON PARK NY
11596-1029
US

V. Phone/Fax

Practice location:
  • Phone: 347-209-6566
  • Fax:
Mailing address:
  • Phone: 347-209-6566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number016978
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: