=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932852241
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMMANUEL PHYSICAL THERAPY SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2022
-----------------------------------------------------
Last Update Date | 01/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5875 NIGHT WIND CIR
-----------------------------------------------------
City | JAMESVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13078-6475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-742-0908
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5875 NIGHT WIND CIR
-----------------------------------------------------
City | JAMESVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13078-6475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-742-0908
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | ANGIELA MARIE GRANJA AURELIO
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 917-742-0908
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------