Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 039069 | NY |
NPI | 1003285313 |
---|---|
Provider Name | Alex Houghtalen |
First Address | Macedon, NY 14502-8943 |
Second Address | Macedon, NY 14502-8943 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2015 |
Last Update Date | 16/09/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
039069 | NYS LICENCE (01) | NY |