Provider Demographics
NPI:1255359444
Name:CERULLO, MICHAEL Q (MSPT,CSCS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:Q
Last Name:CERULLO
Suffix:
Gender:M
Credentials:MSPT,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1 GREENWOOD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3617
Mailing Address - Country:US
Mailing Address - Phone:973-746-2424
Mailing Address - Fax:973-746-5030
Practice Address - Street 1:1 GREENWOOD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3617
Practice Address - Country:US
Practice Address - Phone:973-746-2424
Practice Address - Fax:973-746-5030
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJQA08051225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ038412N5CMedicare ID - Type Unspecified