Provider Demographics
NPI:1699918276
Name:MOGOLLON, ELAINE S (PT)
Entity type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:S
Last Name:MOGOLLON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6 OHIO DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1129
Mailing Address - Country:US
Mailing Address - Phone:718-281-8949
Mailing Address - Fax:516-302-8657
Practice Address - Street 1:6 OHIO DR
Practice Address - Street 2:SUITE 202
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1129
Practice Address - Country:US
Practice Address - Phone:718-281-8949
Practice Address - Fax:516-302-8657
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016726-12251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics