=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609756360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPORTS PHYSICAL THERAPY OCCUPATIONAL THERAPY AND REHABILITATION SERVIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2025
-----------------------------------------------------
Last Update Date | 11/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1103 BOULEVARD E BLDG B
-----------------------------------------------------
City | YAPHANK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11980-7515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-536-3800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 972 BRUSH HOLLOW RD FL 4
-----------------------------------------------------
City | WESTBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11590-1740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-321-7526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, STARS OPERATIONS
-----------------------------------------------------
Name | BRIAN KREBS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-393-8858
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225XH1200X
-----------------------------------------------------
Taxonomy Name | Hand Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------