Provider Demographics
NPI:1689742355
Name:JANECK, KIM M (PT)
Entity Type:Individual
Prefix:MS
First Name:KIM
Middle Name:M
Last Name:JANECK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 CARTERET STREET
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028
Mailing Address - Country:US
Mailing Address - Phone:973-429-2402
Mailing Address - Fax:
Practice Address - Street 1:85 ORIENT WAY
Practice Address - Street 2:
Practice Address - City:RUTHERFORD
Practice Address - State:NJ
Practice Address - Zip Code:07070
Practice Address - Country:US
Practice Address - Phone:201-438-6266
Practice Address - Fax:201-438-5633
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00547000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
088606Medicare ID - Type Unspecified