=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841988524
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MA DANICA PAULA DESABILLE REYES DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2023
-----------------------------------------------------
Last Update Date | 12/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 67 POULTNEY ST
-----------------------------------------------------
City | WHITEHALL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12887-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-812-6479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 67 POULTNEY ST
-----------------------------------------------------
City | WHITEHALL
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12887-1532
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-812-6479
-----------------------------------------------------
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 | 041706-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 040.0134661
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------