Provider Demographics
NPI:1235951112
Name:LEROY, OLIVIA ROSE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ROSE
Last Name:LEROY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 GLENMERE DR
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-1305
Mailing Address - Country:US
Mailing Address - Phone:973-699-5049
Mailing Address - Fax:
Practice Address - Street 1:535 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4823
Practice Address - Country:US
Practice Address - Phone:212-606-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02264100225100000X
NY05314801225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist