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General NPI Number Information
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NPI Number | 1255098919
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Entity Type | Individual
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Provider Name | ROBERT WILSON MT CLT
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Gender | Male
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Dates
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Enumeration Date | 11/17/2021
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Last Update Date | 11/17/2021
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Provider Practice Location Address
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Address Line | 66 NEWARK POMPTON TPKE
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City | RIVERDALE
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State | NJ
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Zip | 07457-1420
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Country | US
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Telephone | 973-858-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 1151 MACOPIN RD
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City | WEST MILFORD
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State | NJ
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Zip | 07480-1508
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Country | US
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Telephone | 201-615-7317
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | 18KT01301400
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License Number State |
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