MEDICARE: A NEW STRIDE P T S L P THERAPEUTIC SERVICES PLLC

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
2	235Z00000X	Speech-Language Pathologist

General Provider Information

NPI Number	:	1700181807
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A NEW STRIDE P T S L P THERAPEUTIC SERVICES PLLC

Provider Business Mailing Address
First Line	:	1779 RICHMOND AVE
Second Line	:	FL 3
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3907
Country	:	US
Telephone Number	:	718-494-5923
Fax Number	:

Provider Business Practice Location Address
First Line	:	1779 RICHMOND AVE
Second Line	:	FL 3
City	:	STATEN ISLAND
State	:	NY
Zip	:	10314-3907
Country	:	US
Telephone Number	:	718-494-5923
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	GEORGE JOHN NICKEL
Credential	:	CCC-SLP
Telephone Number	:	718-494-5923

Provider Enumeration Date	:	01/20/2011
Last Update Date	:	01/20/2011

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