Healthcare Provider Details

I. General information

NPI: 1326190653
Provider Name (Legal Business Name): MAIKUTLO B KEBAETSE PH.D, P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 MANTUA AVE
PAULSBORO NJ
08066-1178
US

IV. Provider business mailing address

PO BOX 277
PAULSBORO NJ
08066-0277
US

V. Phone/Fax

Practice location:
  • Phone: 185-622-4000
  • Fax: 856-224-0466
Mailing address:
  • Phone: 185-622-0400
  • Fax: 856-224-0466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00685900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: