=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104296201
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KERRIN TENGWALL PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2015
-----------------------------------------------------
Last Update Date | 10/01/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 140 SHEPHERDS LN
-----------------------------------------------------
City | TOTOWA
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07512-2188
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-942-0300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 148 VAN AVE
-----------------------------------------------------
City | POMPTON LAKES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07442-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA01632600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------