Provider Demographics
NPI:1699011650
Name:THROCKMORTON, ATHENA MARIE (MPT)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:MARIE
Last Name:THROCKMORTON
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 ALLWOOD RD
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-1988
Mailing Address - Country:US
Mailing Address - Phone:973-928-3590
Mailing Address - Fax:973-928-3589
Practice Address - Street 1:1360 CLIFTON AVE
Practice Address - Street 2:PM BOX 345
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07012-1343
Practice Address - Country:US
Practice Address - Phone:973-928-3590
Practice Address - Fax:973-928-3589
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00875800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist