Healthcare Provider Details

I. General information

NPI: 1346991197
Provider Name (Legal Business Name): ELENA DIBIASE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2022
Last Update Date: 01/13/2022
Certification Date: 12/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 N PARK AVE
SHREWSBURY NJ
07702-4413
US

IV. Provider business mailing address

1120 REMSEN MILL RD
WALL TOWNSHIP NJ
07753-7204
US

V. Phone/Fax

Practice location:
  • Phone: 917-406-0478
  • Fax:
Mailing address:
  • Phone: 845-598-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOT46YR00365900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: