Provider Demographics
NPI:1528945177
Name:KHEDARU, SIMONE (PT,DPT)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:
Last Name:KHEDARU
Suffix:
Gender:X
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MADISON AVENUE
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:212-759-2282
Mailing Address - Fax:212-379-2123
Practice Address - Street 1:25-29 BROADWAY
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106
Practice Address - Country:US
Practice Address - Phone:646-347-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225100000X
NY054975225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist