Basic Information
| Provider Information | |||||||||
| NPI: | 1154672632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BASCIANO | ||||||||
| FirstName: | SERENA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, MSPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FORBES | ||||||||
| OtherFirstName: | SERENA | ||||||||
| OtherMiddleName: | I | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, MPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1014 | ||||||||
| Address2: | |||||||||
| City: | CLARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070661014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328559751 | ||||||||
| FaxNumber: | 7328559755 | ||||||||
| Practice Location | |||||||||
| Address1: | 266-272 CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071056521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737323850 | ||||||||
| FaxNumber: | 9737323853 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2012 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01443500 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 049801DBD | 01 | NJ | MEDICARE | OTHER |