Basic Information
| Provider Information | |||||||||
| NPI: | 1487682597 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAUREEN BRODERICK WILHELM, LPT, PA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPORTS TRAINING PHYSICAL THERAPY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 187 MILLBURN AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MILLBURN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070411847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734677976 | ||||||||
| FaxNumber: | 9734677971 | ||||||||
| Practice Location | |||||||||
| Address1: | 187 MILLBURN AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | MILLBURN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070411847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734677976 | ||||||||
| FaxNumber: | 9734677971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILHELM | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
| AuthorizedOfficialMiddleName: | BRODERICK | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9734677976 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA00333800 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.