Provider Demographics
NPI:1114577855
Name:WASSUM, DANIELLE M (PT, DPT)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:M
Last Name:WASSUM
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 LEXINGTON BLVD APT 6
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1464
Mailing Address - Country:US
Mailing Address - Phone:732-991-6045
Mailing Address - Fax:
Practice Address - Street 1:210 W SAINT GEORGES AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036-3900
Practice Address - Country:US
Practice Address - Phone:908-587-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-15
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01878700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist