Provider Demographics
NPI:1548845712
Name:PEDERSEN, JAMES SEVERIN II (PT, DPT)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:SEVERIN
Last Name:PEDERSEN
Suffix:II
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:PO BOX 182
Mailing Address - Street 2:
Mailing Address - City:GLASCO
Mailing Address - State:NY
Mailing Address - Zip Code:12432-0182
Mailing Address - Country:US
Mailing Address - Phone:845-802-3543
Mailing Address - Fax:
Practice Address - Street 1:96 YORK STREET
Practice Address - Street 2:
Practice Address - City:GLASCO
Practice Address - State:NY
Practice Address - Zip Code:12432
Practice Address - Country:US
Practice Address - Phone:845-802-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist