Provider Demographics
NPI:1497850036
Name:CABAWATAN, MARY GRACE
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:
Last Name:CABAWATAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 EAGLE ROCK AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936-3167
Mailing Address - Country:US
Mailing Address - Phone:201-936-8873
Mailing Address - Fax:
Practice Address - Street 1:610 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-2300
Practice Address - Country:US
Practice Address - Phone:201-217-0600
Practice Address - Fax:201-876-5108
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01096600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist