Healthcare Provider Details

I. General information

NPI: 1316990260
Provider Name (Legal Business Name): AMY MOURAD PT, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 EAGLE ROCK AVE
EAST HANOVER NJ
07936-3101
US

IV. Provider business mailing address

1097 ALPS RD
WAYNE NJ
07470-3708
US

V. Phone/Fax

Practice location:
  • Phone: 222-222-2222
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00962600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: