Provider Demographics
NPI:1639504046
Name:MONGIELLO, MATTHEW J (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:MONGIELLO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07446-2089
Mailing Address - Country:US
Mailing Address - Phone:201-327-1990
Mailing Address - Fax:201-327-1921
Practice Address - Street 1:171 LAKE ST
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:NJ
Practice Address - Zip Code:07446-2089
Practice Address - Country:US
Practice Address - Phone:201-327-1990
Practice Address - Fax:201-327-1921
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01508600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist