Basic Information
Provider Information | |||||||||
NPI: | 1710098538 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLINGMYRE | ||||||||
FirstName: | MERYL | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | YOUNG | ||||||||
OtherFirstName: | MERYL | ||||||||
OtherMiddleName: | A | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PT | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 4 FIR COURT | ||||||||
Address2: |   | ||||||||
City: | SICKLERVILLE | ||||||||
State: | NJ | ||||||||
PostalCode: | 08081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8562273005 | ||||||||
FaxNumber: | 8569120477 | ||||||||
Practice Location | |||||||||
Address1: | 502/503 INDEPENDENCE BLVD. LAKESIDE BUSINESS PARK | ||||||||
Address2: | HEARLAND REHABILITATION SERVICES OF NEW JERSEY, INC | ||||||||
City: | SICKLERVILLE | ||||||||
State: | NJ | ||||||||
PostalCode: | 08081 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8566298777 | ||||||||
FaxNumber: | 8566298771 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01006900 | NJ | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.