{
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"FirstLineMailingAddress": "9309 91ST AVE",
"SecondLineMailingAddress": "SUITE B1",
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"MailingAddressPostalCode": "11421-2745",
"MailingAddressCountryCode": "US",
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"FirstLinePracticeLocationAddress": "9309 91ST AVE",
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"EnumerationDate": "05/02/2007",
"LastUpdateDate": "08/22/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "ELIAS",
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"AuthorizedOfficialTitle": "REGISTERED PHYSICAL THERAPIST",
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"AuthorizedOfficialCredential": "R.P.T",
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"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Physical Therapist",
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"LicenseNumberStateCode": "NY",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}