Provider Demographics
NPI:1366407611
Name:OWEN, NICOLA A (PT)
Entity type:Individual
Prefix:MS
First Name:NICOLA
Middle Name:A
Last Name:OWEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:NICOLA
Other - Middle Name:A
Other - Last Name:TABASSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:224 STRAWBRIDGE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-4602
Mailing Address - Country:US
Mailing Address - Phone:856-677-4000
Mailing Address - Fax:856-234-3014
Practice Address - Street 1:1224 TILTON RD
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1809
Practice Address - Country:US
Practice Address - Phone:609-926-1161
Practice Address - Fax:609-626-3223
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA005727002251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ057734QK7Medicare ID - Type Unspecified