Provider Demographics
NPI:1578834263
Name:PEDIATRIC THERAPY PRACTITIONERS, PA
Entity Type:Organization
Organization Name:PEDIATRIC THERAPY PRACTITIONERS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:BRODERICK
Authorized Official - Last Name:WILHELM
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:973-467-7976
Mailing Address - Street 1:187 MILLBURN AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1847
Mailing Address - Country:US
Mailing Address - Phone:973-467-7976
Mailing Address - Fax:
Practice Address - Street 1:187 MILLBURN AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1847
Practice Address - Country:US
Practice Address - Phone:973-467-7976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00333800261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy