Healthcare Provider Details

I. General information

NPI: 1255754875
Provider Name (Legal Business Name): SHANNON MOTISI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 PLEASANT VALLEY WAY
WEST ORANGE NJ
07052-1424
US

IV. Provider business mailing address

1199 PLEASANT VALLEY WAY
WEST ORANGE NJ
07052-1424
US

V. Phone/Fax

Practice location:
  • Phone: 973-731-3600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number40QA01387200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: