=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316626518
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ORIETTA MAGALY FERNANDEZ MANUAL THERAPIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2023
-----------------------------------------------------
Last Update Date | 08/25/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1135 BROAD ST STE 103
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-3346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-833-1198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 PIAGET AVE
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07011-1216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-640-8989
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 18KT01421500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------