Provider Demographics
NPI:1801060579
Name:COSCOLLUELA, MARILU D (PT)
Entity type:Individual
Prefix:
First Name:MARILU
Middle Name:D
Last Name:COSCOLLUELA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 CRYSTAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-3546
Mailing Address - Country:US
Mailing Address - Phone:973-669-8141
Mailing Address - Fax:973-669-2538
Practice Address - Street 1:50 CRYSTAL AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-3546
Practice Address - Country:US
Practice Address - Phone:973-669-8141
Practice Address - Fax:973-669-2538
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00647800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist