Provider Demographics
NPI:1033402813
Name:DWAILEEBE, LORRAINE ELLEN (MSPT)
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:ELLEN
Last Name:DWAILEEBE
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 MAXWELL LN
Mailing Address - Street 2:#310
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-6823
Mailing Address - Country:US
Mailing Address - Phone:201-937-2758
Mailing Address - Fax:
Practice Address - Street 1:3161 JFK BLVD WEST
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047
Practice Address - Country:US
Practice Address - Phone:201-867-3585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-26
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01231600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist