Healthcare Provider Details

I. General information

NPI: 1851327258
Provider Name (Legal Business Name): MARY GRACE FONDEVILLA SEMBRANO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY GRACE CAPUNO FONDEVILLA PT

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 RIVER AVE
LAKEWOOD NJ
08701
US

IV. Provider business mailing address

16 TULIP COURT
HOWELL NJ
07731
US

V. Phone/Fax

Practice location:
  • Phone: 732-905-0700
  • Fax: 732-364-4566
Mailing address:
  • Phone: 843-276-6709
  • Fax: 732-202-8773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number40QA01021100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01021100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: