=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659915957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUTPATIENT PHYSICAL THERAPY AT HOME, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2019
-----------------------------------------------------
Last Update Date | 01/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 CEDARWOOD CIR
-----------------------------------------------------
City | PITTSFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14534-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-698-7200
-----------------------------------------------------
Fax | 585-244-0664
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 CEDARWOOD CIR
-----------------------------------------------------
City | PITTSFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14534-3246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-698-7200
-----------------------------------------------------
Fax | 585-244-0664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MONIQUE SUSANNE BERG-SPINDELMAN
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 585-698-7200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------