Healthcare Provider Details

I. General information

NPI: 1750550604
Provider Name (Legal Business Name): UNIVERSAL PROGRESSIVE THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 12/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 WASHINGTON AVE SUITE B
NUTLEY NJ
07110-3934
US

IV. Provider business mailing address

242 WASHINGTON AVE SUITE B
NUTLEY NJ
07110-3934
US

V. Phone/Fax

Practice location:
  • Phone: 973-800-6291
  • Fax: 877-591-5378
Mailing address:
  • Phone: 973-800-6291
  • Fax: 877-591-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number46TR00328300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number46TR00328300
License Number StateNJ

VIII. Authorized Official

Name: MRS. VARLEISHA D GIBBS
Title or Position: PRESIDENT
Credential: MS, OTR/L
Phone: 973-800-6291