Provider Demographics
NPI:1316278344
Name:SONG, MIJUNG JUDI (DPT)
Entity type:Individual
Prefix:MS
First Name:MIJUNG
Middle Name:JUDI
Last Name:SONG
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 5TH ST
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2317
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19-21 FAIR LAWN AVE
Practice Address - Street 2:SUITE 1C
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-2331
Practice Address - Country:US
Practice Address - Phone:201-796-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01302400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist