Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2251S0007X | Physical Therapist - Sports | 40QA01298900 | NJ |
Y | 2251X0800X | Physical Therapist - Orthopedic | 40QA01298900 | NJ |
NPI | 1548405772 |
---|---|
Provider Name | Dr. Heidi A. Quackenboss |
First Address | Montclair, NJ 07042-1815 |
Second Address | West Caldwell, NJ 07006-6408 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/12/2008 |
Last Update Date | 02/12/2008 |