Provider Demographics
NPI:1316246895
Name:MASSAPEQUA PT & PTA PLLC
Entity type:Organization
Organization Name:MASSAPEQUA PT & PTA PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:516-454-6387
Mailing Address - Street 1:18 HAMILTON PL
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1915
Mailing Address - Country:US
Mailing Address - Phone:516-454-6387
Mailing Address - Fax:516-454-6303
Practice Address - Street 1:913 N BROADWAY
Practice Address - Street 2:
Practice Address - City:N MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2364
Practice Address - Country:US
Practice Address - Phone:516-454-6387
Practice Address - Fax:516-454-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2013-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020281-12251G0304X, 2251N0400X
NY024174-12251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurologyGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty