MEDICARE: MS. NICOLA A OWEN PT

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	2251S0007X	Sports Physical Therapist	40QA00572700	NJ
2	2251X0800X	Orthopedic Physical Therapist	40QA00572700	NJ
3	225100000X	Physical Therapist	40QA00572700	NJ

General Provider Information

NPI Number	:	1366407611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. NICOLA A OWEN PT

Provider Business Mailing Address
First Line	:	224 STRAWBRIDGE DR STE 100
Second Line	:
City	:	MOORESTOWN
State	:	NJ
Zip	:	08057-4602
Country	:	US
Telephone Number	:	856-677-4000
Fax Number	:	856-234-3014

Provider Business Practice Location Address
First Line	:	1224 TILTON RD
Second Line	:
City	:	NORTHFIELD
State	:	NJ
Zip	:	08225-1809
Country	:	US
Telephone Number	:	609-926-1161
Fax Number	:	609-626-3223

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

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	04/04/2019

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