Healthcare Provider Details

I. General information

NPI: 1548478605
Provider Name (Legal Business Name): MARYSE MUSSAWAR PHYSICAL THERAPIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 ANDREA DR
NORTH CALDWELL NJ
07006-4730
US

IV. Provider business mailing address

44 ANDREA DR
NORTH CALDWELL NJ
07006-4730
US

V. Phone/Fax

Practice location:
  • Phone: 973-256-2504
  • Fax:
Mailing address:
  • Phone: 973-256-2504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00465500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: