Provider Demographics
NPI:1164632436
Name:ANTONSSON, MATERESITA AYUBAN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:MATERESITA
Middle Name:AYUBAN
Last Name:ANTONSSON
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3645
Mailing Address - Country:US
Mailing Address - Phone:973-748-9578
Mailing Address - Fax:
Practice Address - Street 1:267 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3645
Practice Address - Country:US
Practice Address - Phone:973-748-9578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00771900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist