Healthcare Provider Details

I. General information

NPI: 1740559806
Provider Name (Legal Business Name): NOAH L KUBISSA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 GRAND AVE
ENGLEWOOD NJ
07631-4934
US

IV. Provider business mailing address

501 FAIRMOUNT AVE STE 302
TOWSON MD
21286-5494
US

V. Phone/Fax

Practice location:
  • Phone: 201-541-1111
  • Fax:
Mailing address:
  • Phone: 410-927-8768
  • Fax: 410-648-4878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01402400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: