Provider Demographics
NPI:1932840691
Name:MONTCLAIR STATE UNIVERSITY
Entity Type:Organization
Organization Name:MONTCLAIR STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYUDMYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:YAKUBOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-655-7587
Mailing Address - Street 1:1 NORMAL AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1624
Mailing Address - Country:US
Mailing Address - Phone:973-655-7991
Mailing Address - Fax:973-655-5155
Practice Address - Street 1:80 CLOVE RD
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07424-2102
Practice Address - Country:US
Practice Address - Phone:973-655-7991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty