=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306157532
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN CAVITE CRUZ-ROSAL PT,DPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2010
-----------------------------------------------------
Last Update Date | 09/06/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 386 CLUBHOUSE ST
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60490-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-838-0907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16089 POPPYSEED CIR SUITE 2008
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33484-6314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-496-7993
-----------------------------------------------------
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 | 030347
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 070019010
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------