Provider Demographics
NPI:1104150200
Name:TOM, MARIA G (PT)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:G
Last Name:TOM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-5613
Mailing Address - Country:US
Mailing Address - Phone:718-786-1104
Mailing Address - Fax:
Practice Address - Street 1:1024 49TH AVE
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-5613
Practice Address - Country:US
Practice Address - Phone:718-786-1104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010677-12251P0200X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic