Form Physical Therapy Lifestyle Wellness PLLC

Primary specialty

Physical TherapistTaxonomy code 225100000X

Legal business name

FORM PHYSICAL THERAPY LIFESTYLE WELLNESS PLLC

Practice address

21426 41St Ave Ste 110
Bayside, NY 11361-2149

Phone

(718) 279-9800

NPI assigned

Jun 17, 2026

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Dan Thomas

Title

Practice Administrator

Phone

(833) 442-2053

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1781654400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1781654400000",
    "number": "1629903760",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "21426 41ST AVE STE 110",
            "city": "BAYSIDE",
            "state": "NY",
            "postal_code": "113612149",
            "telephone_number": "718-279-9800"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "21426 41ST AVE STE 110",
            "city": "BAYSIDE",
            "state": "NY",
            "postal_code": "113612149",
            "telephone_number": "718-279-9800"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORM PHYSICAL THERAPY LIFESTYLE WELLNESS PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2026-06-17",
        "last_updated": "2026-06-17",
        "certification_date": "2026-06-17",
        "status": "A",
        "authorized_official_last_name": "THOMAS",
        "authorized_official_first_name": "DAN",
        "authorized_official_title_or_position": "PRACTICE ADMINISTRATOR",
        "authorized_official_telephone_number": "833-442-2053",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Physical Therapist in Bayside, NY
• Providers in Bayside, NY by specialty
• Physical Therapist in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.