Provider Demographics
NPI:1962123786
Name:SHARIFIAZAD, TALIA EMILY (DPT)
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:EMILY
Last Name:SHARIFIAZAD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 STEVENSON DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-1823
Mailing Address - Country:US
Mailing Address - Phone:516-567-9297
Mailing Address - Fax:
Practice Address - Street 1:50 GLEN COVE RD
Practice Address - Street 2:
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1062
Practice Address - Country:US
Practice Address - Phone:516-626-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-09
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049463225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist