=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881832244
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ENRICA GONESTO SECIO PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2009
-----------------------------------------------------
Last Update Date | 01/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 RIVER ST SUITE 5A
-----------------------------------------------------
City | HOBOKEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07030-5626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-377-1888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 HEWITT AVE
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10301-4614
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-413-7998
-----------------------------------------------------
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 | 40QA01303000
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------