Healthcare Provider Details

I. General information

NPI: 1205341922
Provider Name (Legal Business Name): JOHN JOSEPH THIEVON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN JOSEPH THIEVON DPT

II. Dates (important events)

Enumeration Date: 12/04/2017
Last Update Date: 12/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 MAIN ST
HACKENSACK NJ
07601-5914
US

IV. Provider business mailing address

605 MAIN ST
HACKENSACK NJ
07601-5914
US

V. Phone/Fax

Practice location:
  • Phone: 201-881-7321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01767400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier22-3033287
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerOUT-PATIENT PHYSICAL THERAPY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: