Provider Demographics
NPI:1629222898
Name:OVALLES, JUAN (MSPT)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:OVALLES
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 ALEXANDER AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-2629
Mailing Address - Country:US
Mailing Address - Phone:917-292-7409
Mailing Address - Fax:973-746-0513
Practice Address - Street 1:69 ALEXANDER AVE
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-2629
Practice Address - Country:US
Practice Address - Phone:917-292-7409
Practice Address - Fax:973-746-0513
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-13
Last Update Date:2008-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023351-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist