MEDICARE: LORRAINE ELLEN DWAILEEBE MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40QA01231600	NJ

General Provider Information

NPI Number	:	1033402813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORRAINE ELLEN DWAILEEBE MSPT

Provider Business Mailing Address
First Line	:	1025 MAXWELL LN
Second Line	:	#310
City	:	HOBOKEN
State	:	NJ
Zip	:	07030-6823
Country	:	US
Telephone Number	:	201-937-2758
Fax Number	:

Provider Business Practice Location Address
First Line	:	3161 JFK BLVD WEST
Second Line	:
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047
Country	:	US
Telephone Number	:	201-867-3585
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2011
Last Update Date	:	05/26/2011

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