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General NPI Number Information
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NPI Number | 1679071740
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Entity Type | Organization
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Legal Business Name | MBG THERAPY
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Dates
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Enumeration Date | 01/24/2018
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Last Update Date | 01/24/2018
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Provider Practice Location Address
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Address Line | 7 AMY DR
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City | WESTFIELD
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State | NJ
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Zip | 07090-2619
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Country | US
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Telephone | 732-580-3539
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Fax | 847-886-7525
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Provider Business Mailing Address
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Address Line | 7 AMY DR
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City | WESTFIELD
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State | NJ
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Zip | 07090-2619
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Country | US
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Telephone | 732-580-3539
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Fax | 847-886-7525
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Authorized Official
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Title or Position | THERAPIST
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Name | MARISSA VASTOLER
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Credential |
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Telephone | 732-580-3539
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 41YS00596800
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License Number State | NJ
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