=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821745308
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOAN WHITTAKER PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2022
-----------------------------------------------------
Last Update Date | 03/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1060 MAIN ST
-----------------------------------------------------
City | RIVER EDGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07661-2591
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-833-0234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 403 WEST AVE
-----------------------------------------------------
City | NORTHVALE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07647-1308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 40QA00225900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------