Provider Demographics
NPI:1285004713
Name:YUBA, KEIKO
Entity type:Individual
Prefix:
First Name:KEIKO
Middle Name:
Last Name:YUBA
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 1:24 WAGNER PL
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-1334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 WAGNER PL
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NJ
Practice Address - Zip Code:07506-1334
Practice Address - Country:US
Practice Address - Phone:201-995-3771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-26
Last Update Date:2015-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01546000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist