Provider Demographics
NPI:1104088798
Name:MAENG, KI TAE (PT)
Entity type:Individual
Prefix:
First Name:KI TAE
Middle Name:
Last Name:MAENG
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 PARSONS BLVD APT L1
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5929
Mailing Address - Country:US
Mailing Address - Phone:718-353-7575
Mailing Address - Fax:718-353-7577
Practice Address - Street 1:3625 PARSONS BLVD
Practice Address - Street 2:UNIT L1
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-353-7575
Practice Address - Fax:718-353-7577
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist