Provider Demographics
NPI:1215422183
Name:CABALZA, JOHANNA NOLASCO
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:NOLASCO
Last Name:CABALZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 N BROADWAY APT G1
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-3775
Mailing Address - Country:US
Mailing Address - Phone:914-831-7309
Mailing Address - Fax:
Practice Address - Street 1:79 N BROADWAY APT G1
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603
Practice Address - Country:US
Practice Address - Phone:914-831-7309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-24
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty