Provider Demographics
NPI:1982961470
Name:SECILLANO, TEDDY (PT)
Entity Type:Individual
Prefix:MR
First Name:TEDDY
Middle Name:
Last Name:SECILLANO
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 1:321 PROSPECT AVE.
Mailing Address - Street 2:APT 5D
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-2593
Mailing Address - Country:US
Mailing Address - Phone:718-404-4462
Mailing Address - Fax:
Practice Address - Street 1:9020 WALL ST
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-6011
Practice Address - Country:US
Practice Address - Phone:201-861-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2012-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA014201002251G0304X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic