MEDICARE: MS. AUTUMN LEBANK 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	033968	NY

General Provider Information

NPI Number	:	1417221979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AUTUMN LEBANK DPT

Provider Business Mailing Address
First Line	:	745 PRESIDENT ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-1303
Country	:	US
Telephone Number	:	503-931-1946
Fax Number	:

Provider Business Practice Location Address
First Line	:	745 PRESIDENT ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11215-1303
Country	:	US
Telephone Number	:	503-931-1946
Fax Number	:

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

Provider Enumeration Date	:	03/01/2012
Last Update Date	:	12/10/2014

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