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General NPI Number Information
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NPI Number | 1114968872
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Entity Type | Individual
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Provider Name | REGINA GRACE POWERS P.T.,M.S.
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Gender | Female
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Dates
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Enumeration Date | 06/10/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 128 OLD TOWN RD LOWER LEVEL @ SETAUKET OFFICE PARK
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City | EAST SETAUKET
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State | NY
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Zip | 11733-2064
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Country | US
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Telephone | 631-444-5603
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Fax | 631-444-5604
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Provider Business Mailing Address
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Address Line | 123 HICKORY ST
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-2117
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Country | US
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Telephone | 631-444-5603
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Fax | 631-444-5604
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 008596-1
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License Number State | NY
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