Provider Demographics
NPI:1023626280
Name:LIBRADILLA, JAE (PT)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:LIBRADILLA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 GATES AVE.
Mailing Address - Street 2:
Mailing Address - City:OSSINING
Mailing Address - State:NY
Mailing Address - Zip Code:10562
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1560 MAYFLOWER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5400
Practice Address - Country:US
Practice Address - Phone:718-948-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041084225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist