Healthcare Provider Details

I. General information

NPI: 1730739020
Provider Name (Legal Business Name): SHAPE UP THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2019
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 WATERVIEW DR
LAKEWOOD NJ
08701-4312
US

IV. Provider business mailing address

35 WATERVIEW DR
LAKEWOOD NJ
08701-4312
US

V. Phone/Fax

Practice location:
  • Phone: 917-676-6426
  • Fax:
Mailing address:
  • Phone: 917-676-6426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEXANDER GUTTMAN
Title or Position: DIRECTOR
Credential:
Phone: 917-676-6426