Provider Demographics
NPI:1730645581
Name:WIZZARD, SHAENA OLIVIA (PT, DPT)
Entity Type:Individual
Prefix:MISS
First Name:SHAENA
Middle Name:OLIVIA
Last Name:WIZZARD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 VOORHEES ST
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-6333
Mailing Address - Country:US
Mailing Address - Phone:201-673-2736
Mailing Address - Fax:
Practice Address - Street 1:156 VOORHEES ST
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-6333
Practice Address - Country:US
Practice Address - Phone:201-673-2736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01846100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist