Provider Demographics
NPI:1144282385
Name:DEGEORGE, TINA MARIE (MSPT)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:DEGEORGE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4360 AUTUMN TRL
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:NY
Mailing Address - Zip Code:14031-2301
Mailing Address - Country:US
Mailing Address - Phone:716-698-2428
Mailing Address - Fax:
Practice Address - Street 1:2900 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-2309
Practice Address - Country:US
Practice Address - Phone:716-871-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0280621225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist