Provider Demographics
NPI:1588855308
Name:DIVINAGRACIA, ELIZABETH BULOSAN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:BULOSAN
Last Name:DIVINAGRACIA
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:VILLASENOR
Other - Last Name:BULOSAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICAL THERAPIST
Mailing Address - Street 1:3 ROSE COURT 2ND FOR
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002
Mailing Address - Country:US
Mailing Address - Phone:201-993-9344
Mailing Address - Fax:201-433-4772
Practice Address - Street 1:9 POST RD STE M12
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:NJ
Practice Address - Zip Code:07436-1615
Practice Address - Country:US
Practice Address - Phone:201-651-0062
Practice Address - Fax:201-651-7723
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2016-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00953000111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ050967Medicare PIN