Provider Demographics
NPI:1144618901
Name:VASANTH, VISALAM (DPT)
Entity Type:Individual
Prefix:DR
First Name:VISALAM
Middle Name:
Last Name:VASANTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7457 RIVERSIDE STATION BLVD
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-4458
Mailing Address - Country:US
Mailing Address - Phone:201-822-1613
Mailing Address - Fax:
Practice Address - Street 1:7457 RIVERSIDE STATION BLVD
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-4458
Practice Address - Country:US
Practice Address - Phone:201-822-1613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01545500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist