Basic Information
| Provider Information | |||||||||
| NPI: | 1194094276 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEMBERTON | ||||||||
| FirstName: | LAWRENCE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1014 | ||||||||
| Address2: | |||||||||
| City: | CLARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070661014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328559751 | ||||||||
| FaxNumber: | 7328559755 | ||||||||
| Practice Location | |||||||||
| Address1: | 33 BLEEKER ST STE 102 | ||||||||
| Address2: | |||||||||
| City: | MILLBURN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070411460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732581900 | ||||||||
| FaxNumber: | 7328559755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2011 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01481500 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 1210060 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 8990 | TN | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.