Provider Demographics
NPI:1417993338
Name:WESTON PAXXON PT, OT & SLP, PLLC.
Entity type:Organization
Organization Name:WESTON PAXXON PT, OT & SLP, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:BERKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:631-467-3700
Mailing Address - Street 1:20 PEACHTREE CT
Mailing Address - Street 2:SUITE 105
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4616
Mailing Address - Country:US
Mailing Address - Phone:631-467-3700
Mailing Address - Fax:631-467-0928
Practice Address - Street 1:11701 84TH AVE
Practice Address - Street 2:SUITE 915
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11418-1420
Practice Address - Country:US
Practice Address - Phone:718-441-0479
Practice Address - Fax:718-441-0479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003194-12251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ7W6U1Medicare PIN