Provider Demographics
NPI:1275053944
Name:BURSESE, AMANDA THERESA (DPT)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:THERESA
Last Name:BURSESE
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 1:123 KNOLL TER
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7300
Mailing Address - Country:US
Mailing Address - Phone:973-461-6337
Mailing Address - Fax:
Practice Address - Street 1:65 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3001
Practice Address - Country:US
Practice Address - Phone:973-461-6337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040788-1225100000X
NJ40QA01621700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist