Basic Information
| Provider Information | |||||||||
| NPI: | 1952459067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERUBE | ||||||||
| FirstName: | ALLYSON | ||||||||
| MiddleName: | DORA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JENGO | ||||||||
| OtherFirstName: | ALLYSON | ||||||||
| OtherMiddleName: | DORA | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11 EAGLE ROCK AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | EAST HANOVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079363101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738879000 | ||||||||
| FaxNumber: | 9738873816 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 PARK AVE | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | HILLSDALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076422057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2012630001 | ||||||||
| FaxNumber: | 2012630002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 09/02/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01170800 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.