=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629890736
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARYAM ARNERIS REBISZ PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2024
-----------------------------------------------------
Last Update Date | 10/29/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1423 E MAIN
-----------------------------------------------------
City | PUYALLUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98372-3138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-881-1362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 268 DIVISION AVE
-----------------------------------------------------
City | BELLEVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07109-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-217-0370
-----------------------------------------------------
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 | 40QA01844500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------