MEDICARE: CRESTWATER PHYSICAL THERAPY

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	174400000X	Specialist	021464-1	NY

General Provider Information

NPI Number	:	1487039905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRESTWATER PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	7129 5TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-1678
Country	:	US
Telephone Number	:	718-745-1313
Fax Number	:

Provider Business Practice Location Address
First Line	:	7129 5TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-1678
Country	:	US
Telephone Number	:	718-745-1313
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MAI ABDALLA
Credential	:	DPT
Telephone Number	:	718-745-1313

Provider Enumeration Date	:	07/27/2015
Last Update Date	:	07/27/2015

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