Provider Demographics
NPI:1144778606
Name:LOZADA, MARY RACHEL PORTILLO (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY RACHEL
Middle Name:PORTILLO
Last Name:LOZADA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 S WASHINGTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-2341
Mailing Address - Country:US
Mailing Address - Phone:315-591-5630
Mailing Address - Fax:
Practice Address - Street 1:108 S WASHINGTON AVE STE B
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-2341
Practice Address - Country:US
Practice Address - Phone:315-591-5630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01671600261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy