Provider Demographics
NPI:1316917560
Name:WORMOLD, EDWARD (PTA)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:
Last Name:WORMOLD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 PALO ALTO DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-2811
Mailing Address - Country:US
Mailing Address - Phone:631-283-4190
Mailing Address - Fax:631-283-7650
Practice Address - Street 1:167 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-4823
Practice Address - Country:US
Practice Address - Phone:631-283-4190
Practice Address - Fax:631-283-7650
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003464-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant