=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356963367
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRINCIPAL PHYSICAL THERAPY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2020
-----------------------------------------------------
Last Update Date | 01/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 8TH AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11217-3958
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-679-3659
-----------------------------------------------------
Fax | 855-820-1237
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 ROGERS AVE APT 2RE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11216-6000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. SUZE-ELISHA PRINCIPAL
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 718-679-3659
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------