Healthcare Provider Details

I. General information

NPI: 1417827908
Provider Name (Legal Business Name): INNOVATIVE PHYSICAL THERAPY AND WELLNESS OF NJ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 MANTUA PIKE
WOODBURY HEIGHTS NJ
08097-1221
US

IV. Provider business mailing address

111 TOWN SQUARE PLACE STE 1238 #808828
JERSEY CITY NJ
07310-1810
US

V. Phone/Fax

Practice location:
  • Phone: 443-512-8337
  • Fax: 443-327-5282
Mailing address:
  • Phone: 443-512-8337
  • Fax: 443-327-8252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: WILLIA HOLLAND
Title or Position: OWNER
Credential: DPT
Phone: 302-275-8670