Provider Demographics
NPI:1548405772
Name:QUACKENBOSS, HEIDI A (DPT)
Entity Type:Individual
Prefix:DR
First Name:HEIDI
Middle Name:A
Last Name:QUACKENBOSS
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 1:415 CLAREMONT AVE APT 1C
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-1815
Mailing Address - Country:US
Mailing Address - Phone:973-233-1312
Mailing Address - Fax:
Practice Address - Street 1:700 PASSAIC AVE
Practice Address - Street 2:
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-6408
Practice Address - Country:US
Practice Address - Phone:973-575-7576
Practice Address - Fax:973-575-7985
Is Sole Proprietor?:No
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA012989002251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports