Provider Demographics
NPI:1871094896
Name:ESTRADA, EDALYN MAE
Entity type:Individual
Prefix:
First Name:EDALYN MAE
Middle Name:
Last Name:ESTRADA
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 1:71-20 110TH STREET
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:718-710-7095
Mailing Address - Fax:
Practice Address - Street 1:71-20 110TH STREET
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-305-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-25
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042817225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist