Provider Demographics
NPI:1952459067
Name:BERUBE, ALLYSON DORA (PT)
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:DORA
Last Name:BERUBE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:ALLYSON
Other - Middle Name:DORA
Other - Last Name:JENGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:11 EAGLE ROCK AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936-3101
Mailing Address - Country:US
Mailing Address - Phone:973-887-9000
Mailing Address - Fax:973-887-3816
Practice Address - Street 1:100 PARK AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:HILLSDALE
Practice Address - State:NJ
Practice Address - Zip Code:07642-2057
Practice Address - Country:US
Practice Address - Phone:201-263-0001
Practice Address - Fax:201-263-0002
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01170800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ115025Medicare PIN