=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235738188
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDAN WILLIAMS BACON PT, DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2020
-----------------------------------------------------
Last Update Date | 10/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 BUSINESS PARK DR
-----------------------------------------------------
City | ARMONK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10504-1727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-273-3413
-----------------------------------------------------
Fax | 914-273-3036
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18 ALBION OVAL
-----------------------------------------------------
City | MAHOPAC
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10541-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-264-4953
-----------------------------------------------------
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 | 046326
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------