Basic Information
| Provider Information | |||||||||
| NPI: | 1780295717 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ABDUL-JABBAAR | ||||||||
| FirstName: | KHALEEL | ||||||||
| MiddleName: | LEROY | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27 TACOMA ST | ||||||||
| Address2: | |||||||||
| City: | HYDE PARK | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021363203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8572046228 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1493 CAMBRIDGE ST | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021391047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176651000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2020 | ||||||||
| LastUpdateDate: | 08/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 25136 | MA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.