Provider Demographics
NPI:1629569942
Name:BREATHE LIFE PHYSICAL THERAPY & WELLNESS
Entity Type:Organization
Organization Name:BREATHE LIFE PHYSICAL THERAPY & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPY
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERITAGE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:856-210-3517
Mailing Address - Street 1:91 STOKES RD
Mailing Address - Street 2:
Mailing Address - City:SHAMONG
Mailing Address - State:NJ
Mailing Address - Zip Code:08088-9449
Mailing Address - Country:US
Mailing Address - Phone:856-210-3517
Mailing Address - Fax:
Practice Address - Street 1:915 HADDON AVE
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108
Practice Address - Country:US
Practice Address - Phone:856-905-4712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJPT40QA01426900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty