Healthcare Provider Details

I. General information

NPI: 1497304430
Provider Name (Legal Business Name): BRAVE WINGS THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 PASSAIC AVE
FAIRFIELD NJ
07004-3561
US

IV. Provider business mailing address

155 PASSAIC AVE
FAIRFIELD NJ
07004-3561
US

V. Phone/Fax

Practice location:
  • Phone: 973-747-0456
  • Fax:
Mailing address:
  • Phone: 973-747-0456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER D. MOORE
Title or Position: OWNER
Credential:
Phone: 973-747-0456