MEDICARE: SPORTS BARRE PHYSICAL THERAPY LLC

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

General Provider Information

NPI Number	:	1730873308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTS BARRE PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	470 OLD STONE RD
Second Line	:
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-1417
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 OLD STONE RD
Second Line	:
City	:	RIDGEWOOD
State	:	NJ
Zip	:	07450-1417
Country	:	US
Telephone Number	:	201-835-7664
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR OF PHYSICAL THERAPY
Name	:	DR. JILLIAN CASELLA
Credential	:	PT, DPT
Telephone Number	:	201-835-7664

Provider Enumeration Date	:	06/06/2023
Last Update Date	:	06/06/2023

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