=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184877656
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL JOSEPH CANTARA PT, DPT, MA, PCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2008
-----------------------------------------------------
Last Update Date | 10/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 143 BROMLEIGH RD
-----------------------------------------------------
City | STEWART MANOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-352-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 143 BROMLEIGH RD
-----------------------------------------------------
City | STEWART MANOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11530-5013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-352-3030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 016562-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251P0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Physical Therapist
-----------------------------------------------------
License Number | 016562-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------