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General NPI Number Information
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NPI Number | 1205118429
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Entity Type | Organization
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Legal Business Name | ST JUDES PT
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Dates
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Enumeration Date | 09/14/2011
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Last Update Date | 09/14/2011
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Provider Practice Location Address
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Address Line | 212 MACON ST 2ND FLOOR
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City | BROOKLYN
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State | NY
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Zip | 11216-2405
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Country | US
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Telephone | 718-238-0311
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Fax |
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Provider Business Mailing Address
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Address Line | 7712 4TH AVE FIRST FLOOR
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City | BROOKLYN
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State | NY
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Zip | 11209-3402
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Country | US
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Telephone | 718-238-0311
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. KEISHA E JOHN
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Credential | DPT
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Telephone | 718-238-0311
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | 015866
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 2251P0200X
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Taxonomy Name | Pediatric Physical Therapist
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License Number | 028641
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License Number State | NY
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