Provider Demographics
NPI:1679389167
Name:BLACK, JOSE (PT, DPT)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 TOMPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10570-3146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220 TOMPKINS AVE
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NY
Practice Address - Zip Code:10570-3146
Practice Address - Country:US
Practice Address - Phone:914-358-2900
Practice Address - Fax:212-298-9888
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist