MEDICARE: LAURA BUCKHOLZ PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	035129	NY

General Provider Information

NPI Number	:	1174870208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA BUCKHOLZ PT, DPT

Provider Business Mailing Address
First Line	:	507 W 147TH ST
Second Line	:	APT 26
City	:	NEW YORK
State	:	NY
Zip	:	10031-4432
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	507 W 147TH ST
Second Line	:	APT 26
City	:	NEW YORK
State	:	NY
Zip	:	10031-4432
Country	:	US
Telephone Number	:	917-684-9873
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2012
Last Update Date	:	08/08/2012

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