Provider Demographics
NPI:1275696411
Name:JANNICELLI-CLARE, MARY-LOUISE (PT)
Entity Type:Individual
Prefix:
First Name:MARY-LOUISE
Middle Name:
Last Name:JANNICELLI-CLARE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:MARY-LOUISE
Other - Middle Name:
Other - Last Name:JANNICELLI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:264 BOYDEN AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3070
Mailing Address - Country:US
Mailing Address - Phone:973-761-0764
Mailing Address - Fax:973-761-0112
Practice Address - Street 1:21 THE TERRACE
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070
Practice Address - Country:US
Practice Address - Phone:201-460-7459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00419300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist