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Organization
ST JUDE'S PHYSICAL THERAPY
Active
Organization
ST JUDE'S PHYSICAL THERAPY
Active
Other names
St Jude's Pediatric Services
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KEISHA E JOHN DPT (CO-PRESIDENT)
(347) 524-0630
Entity
Organization
Contact information
Practice address
7712 4TH AVE, # 1, BROOKLYN, NY 11209-3402
(646) 224-8040
Mailing address
212 MACON ST, 2ND FLOOR, BROOKLYN, NY 11216-2405
(347) 524-0630
(646) 224-8040
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
028641
NY
225XP0200X
Pediatric Occupational Therapist
016896-1
NY
235Z00000X
Speech-Language Pathologist
020555-1
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03130458
—
NY
01
—
A400016264
MEDICARE
NY
Enumeration date
06/21/2011
Last updated
11/23/2011
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