Provider Demographics
NPI:1083900740
Name:WOLBACH, JANE KHANTZIAN (MSPT)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:KHANTZIAN
Last Name:WOLBACH
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 1:70 BUTLER STREET
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079
Mailing Address - Country:US
Mailing Address - Phone:603-893-2900
Mailing Address - Fax:603-893-1628
Practice Address - Street 1:70 BUTLER STREET
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079
Practice Address - Country:US
Practice Address - Phone:603-893-2900
Practice Address - Fax:603-893-1628
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3126225100000X
MA8982225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist