Provider Demographics
NPI:1275076366
Name:TABABA, BRIAN (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:TABABA
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-6116
Mailing Address - Country:US
Mailing Address - Phone:908-463-0966
Mailing Address - Fax:
Practice Address - Street 1:1025 HARDING AVE
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-6116
Practice Address - Country:US
Practice Address - Phone:908-463-0966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-22
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01705000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist