Provider Demographics
NPI:1932256682
Name:MAIRELLA, KATHLEEN K (PT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:K
Last Name:MAIRELLA
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 1:256 WHITFORD AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1820
Mailing Address - Country:US
Mailing Address - Phone:973-661-0543
Mailing Address - Fax:
Practice Address - Street 1:189 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3823
Practice Address - Country:US
Practice Address - Phone:973-235-9585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00196400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist