Provider Demographics
NPI:1750390787
Name:PURCELL, TIMOTHY LARSON (PT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LARSON
Last Name:PURCELL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:162 GARDEN AVE
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-1937
Mailing Address - Country:US
Mailing Address - Phone:201-401-0859
Mailing Address - Fax:888-568-4217
Practice Address - Street 1:162 GARDEN AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-1937
Practice Address - Country:US
Practice Address - Phone:201-401-0859
Practice Address - Fax:888-568-4217
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA007946002251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1750390787Medicaid