Provider Demographics
NPI:1083987671
Name:EUGENE, ROSELAURE (PTA)
Entity type:Individual
Prefix:
First Name:ROSELAURE
Middle Name:
Last Name:EUGENE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-2005
Mailing Address - Country:US
Mailing Address - Phone:516-242-4954
Mailing Address - Fax:718-782-5930
Practice Address - Street 1:21 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-2005
Practice Address - Country:US
Practice Address - Phone:516-242-4954
Practice Address - Fax:718-782-5930
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY66002453225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant