Provider Demographics
NPI:1124324942
Name:MINERVA, JUSTIN ANDREW (DPT)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:ANDREW
Last Name:MINERVA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 CANBY CT
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2309
Mailing Address - Country:US
Mailing Address - Phone:631-482-8870
Mailing Address - Fax:
Practice Address - Street 1:11 CANBY CT
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-2309
Practice Address - Country:US
Practice Address - Phone:631-482-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-27
Last Update Date:2016-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031214-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist