Provider Demographics
NPI:1679817126
Name:TUBIAK, RENATA (PTA)
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:
Last Name:TUBIAK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20B TRIUMPH CT
Mailing Address - Street 2:
Mailing Address - City:EAST RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07073-1147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3161 KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-2303
Practice Address - Country:US
Practice Address - Phone:201-867-3585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00257500225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant