Provider Demographics
NPI:1013352244
Name:MINDFUL PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MINDFUL PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:P
Authorized Official - Last Name:FAGERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:267-432-1795
Mailing Address - Street 1:119 SHIPPEN RD
Mailing Address - Street 2:
Mailing Address - City:ERDENHEIM
Mailing Address - State:PA
Mailing Address - Zip Code:19038-7306
Mailing Address - Country:US
Mailing Address - Phone:267-432-1795
Mailing Address - Fax:
Practice Address - Street 1:119 SHIPPEN RD
Practice Address - Street 2:
Practice Address - City:ERDENHEIM
Practice Address - State:PA
Practice Address - Zip Code:19038-7306
Practice Address - Country:US
Practice Address - Phone:267-432-1795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT-003491-L261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1053558171OtherINDIVIDUAL NPI