Provider Demographics
NPI:1063542363
Name:PAMELA ROUSSELL PHYSICAL THERAPY AND WELLNESS
Entity type:Organization
Organization Name:PAMELA ROUSSELL PHYSICAL THERAPY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST PRACTICE OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ROUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:732-842-9100
Mailing Address - Street 1:354 CONOVER PLACE
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-842-9100
Mailing Address - Fax:
Practice Address - Street 1:354 CONOVER PLACE
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701
Practice Address - Country:US
Practice Address - Phone:732-842-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA05714225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00011543OtherRAILROAD MEDICARE
P00011543OtherRAILROAD MEDICARE