Provider Demographics
NPI:1336603711
Name:GOTTLIEB, MARISSA (DPT)
Entity Type:Individual
Prefix:MISS
First Name:MARISSA
Middle Name:
Last Name:GOTTLIEB
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 ROUTE 34
Mailing Address - Street 2:
Mailing Address - City:MATAWAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07747-2132
Mailing Address - Country:US
Mailing Address - Phone:732-320-6285
Mailing Address - Fax:732-374-9864
Practice Address - Street 1:3276 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:PARLIN
Practice Address - State:NJ
Practice Address - Zip Code:08859-1676
Practice Address - Country:US
Practice Address - Phone:732-238-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-30
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01829000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01829000OtherPT LICENSE NUMBER