Provider Demographics
NPI:1679698484
Name:LE BRETON, FARA DESFOR (PT, MSC, MACP)
Entity type:Individual
Prefix:MRS
First Name:FARA
Middle Name:DESFOR
Last Name:LE BRETON
Suffix:
Gender:F
Credentials:PT, MSC, MACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W 71ST ST
Mailing Address - Street 2:#5A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3876
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 W 57TH ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3916
Practice Address - Country:US
Practice Address - Phone:212-317-9798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016820-12251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic