Provider Demographics
NPI:1427284025
Name:FORMOSO-SANTOS, MARICRIS (PT)
Entity type:Individual
Prefix:
First Name:MARICRIS
Middle Name:
Last Name:FORMOSO-SANTOS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9-11 WESTMORELAND AVE # 401
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1923
Mailing Address - Country:US
Mailing Address - Phone:646-918-4670
Mailing Address - Fax:
Practice Address - Street 1:9-11 WESTMORELAND AVE # 401
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1923
Practice Address - Country:US
Practice Address - Phone:646-918-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-09
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028196-1225100000X
NJ40QA01313000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist