MEDICARE: MISS ENRICA GONESTO SECIO PT

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	40QA01303000	NJ

General Provider Information

NPI Number	:	1881832244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ENRICA GONESTO SECIO PT

Provider Business Mailing Address
First Line	:	8 HEWITT AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10301-4614
Country	:	US
Telephone Number	:	240-413-7998
Fax Number	:

Provider Business Practice Location Address
First Line	:	80 RIVER ST
Second Line	:	SUITE 5A
City	:	HOBOKEN
State	:	NJ
Zip	:	07030-5626
Country	:	US
Telephone Number	:	201-377-1888
Fax Number	:

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

Provider Enumeration Date	:	01/22/2009
Last Update Date	:	01/22/2009

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