Healthcare Provider Details

I. General information

NPI: 1750031126
Provider Name (Legal Business Name): CHANTELL CRISAN COORE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 TILDEN AVE
TEANECK NJ
07666-2507
US

IV. Provider business mailing address

515 TILDEN AVE
TEANECK NJ
07666-2507
US

V. Phone/Fax

Practice location:
  • Phone: 551-275-9999
  • Fax:
Mailing address:
  • Phone: 551-275-3050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number304181
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA02079300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: