Basic Information
| Provider Information | |||||||||
| NPI: | 1841545688 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUES | ||||||||
| FirstName: | NATALIE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT, CLT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BACCILE | ||||||||
| OtherFirstName: | NATALIE | ||||||||
| OtherMiddleName: | TALIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1014 | ||||||||
| Address2: | |||||||||
| City: | CLARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070661014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328559751 | ||||||||
| FaxNumber: | 7328559755 | ||||||||
| Practice Location | |||||||||
| Address1: | 24-17 FAIR LAWN AVE | ||||||||
| Address2: | |||||||||
| City: | FAIR LAWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074103429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2017944417 | ||||||||
| FaxNumber: | 2017944419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 06/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 40QA01448200 | NJ | N | Other Service Providers | Specialist | 225100000X | 40QA01448200 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.