Provider Demographics
NPI:1114963063
Name:MAUREEN BRODERICK WILHELM LPT PA
Entity Type:Organization
Organization Name:MAUREEN BRODERICK WILHELM LPT PA
Other - Org Name:SPORTS TRAINING PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:BRODERICK
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:973-467-7976
Mailing Address - Street 1:187 MILLBURN AVENUE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041
Mailing Address - Country:US
Mailing Address - Phone:973-467-7976
Mailing Address - Fax:973-467-7971
Practice Address - Street 1:187 MILLBURN AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041
Practice Address - Country:US
Practice Address - Phone:973-467-7976
Practice Address - Fax:973-467-7971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ080169Medicare ID - Type Unspecified