Provider Demographics
NPI:1871144139
Name:SONG, GRACE EUNBI (DPT)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:EUNBI
Last Name:SONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:JEONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3342 149TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-3242
Mailing Address - Country:US
Mailing Address - Phone:646-266-8564
Mailing Address - Fax:
Practice Address - Street 1:90 E SHORE RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2409
Practice Address - Country:US
Practice Address - Phone:516-684-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-26
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044918-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist