Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 023501 | NY |
Y | 2251P0200X | Physical Therapist - Pediatrics | 023501 | NY |
NPI | 1063666568 |
---|---|
Provider Name | Haridimos Kanellopoulos |
First Address | Seaford, NY 11783-2710 |
Second Address | Seaford, NY 11783-2710 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/11/2008 |
Last Update Date | 11/11/2008 |