Provider Demographics
NPI:1881716702
Name:BRAVO, RIZARUTH MARCOS (PT)
Entity type:Individual
Prefix:
First Name:RIZARUTH
Middle Name:MARCOS
Last Name:BRAVO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:RIZARUTH
Other - Middle Name:CORTEZ
Other - Last Name:MARCOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:941 BOULEVARD
Mailing Address - Street 2:APT. B
Mailing Address - City:NEW MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07646-6430
Mailing Address - Country:US
Mailing Address - Phone:201-483-3912
Mailing Address - Fax:201-483-3912
Practice Address - Street 1:100 MCCLELLEN ST
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07648-1555
Practice Address - Country:US
Practice Address - Phone:201-768-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01183900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ40QA01183900OtherPHYSICAL THERAPIST LIC.#