Provider Demographics
NPI:1497304430
Name:BRAVE WINGS THERAPY, PC
Entity Type:Organization
Organization Name:BRAVE WINGS THERAPY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-DIRECTOR/SLP
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD CCC-SLP
Authorized Official - Phone:973-800-8515
Mailing Address - Street 1:1211 HAMBURG TPKE STE 224
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-5056
Mailing Address - Country:US
Mailing Address - Phone:973-800-8515
Mailing Address - Fax:
Practice Address - Street 1:1211 HAMBURG TPKE STE 224
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-5056
Practice Address - Country:US
Practice Address - Phone:973-800-8515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-11
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty