Provider Demographics
NPI:1518573070
Name:PARK, DENISE (DPT)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:PARK
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 1:260 1ST ST APT B1
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-2302
Mailing Address - Country:US
Mailing Address - Phone:917-717-0717
Mailing Address - Fax:
Practice Address - Street 1:260 1ST ST APT B1
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-2302
Practice Address - Country:US
Practice Address - Phone:917-717-0717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist