MEDICARE: MS. PURISSA A SEVILLE P.T.

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	QA008403	NJ

General Provider Information

NPI Number	:	1497738579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PURISSA A SEVILLE P.T.

Provider Business Mailing Address
First Line	:	233 GARDEN PL
Second Line	:
City	:	ORADELL
State	:	NJ
Zip	:	07649-2217
Country	:	US
Telephone Number	:	201-893-1995
Fax Number	:	201-483-6527

Provider Business Practice Location Address
First Line	:	233 GARDEN PL
Second Line	:
City	:	ORADELL
State	:	NJ
Zip	:	07649-2217
Country	:	US
Telephone Number	:	201-893-1995
Fax Number	:	201-483-6527

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

Provider Enumeration Date	:	11/22/2005
Last Update Date	:	04/24/2014

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