Provider Demographics
NPI:1285118299
Name:GOOD SHEPHERD PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:GOOD SHEPHERD PHYSICAL THERAPY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DPT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAQUI
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:201-660-0968
Mailing Address - Street 1:107 E BROADWAY FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-7037
Mailing Address - Country:US
Mailing Address - Phone:212-233-0889
Mailing Address - Fax:212-233-0898
Practice Address - Street 1:107 E BROADWAY FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-7037
Practice Address - Country:US
Practice Address - Phone:201-660-0968
Practice Address - Fax:212-233-0898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-17
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1386023018Medicaid