=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215624432
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PELVIC HEALTH AND AWARENESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2023
-----------------------------------------------------
Last Update Date | 04/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 166 FAIRVIEW AVE STE F
-----------------------------------------------------
City | WESTWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675-2279
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-780-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 76 STRATTON AVE
-----------------------------------------------------
City | WESTWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675-2851
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-780-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | JENNIFER COLLARD FORNS
-----------------------------------------------------
Credential | PT, PRPC
-----------------------------------------------------
Telephone | 201-780-3500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------