Provider Demographics
NPI:1487105615
Name:PRIMAL PHYSICAL THERAPY ,LLC
Entity type:Organization
Organization Name:PRIMAL PHYSICAL THERAPY ,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:J
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:302-897-8496
Mailing Address - Street 1:124 N EDMONDS AVE
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-5023
Mailing Address - Country:US
Mailing Address - Phone:302-897-8496
Mailing Address - Fax:484-489-2787
Practice Address - Street 1:905 W LANCASTER AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3011
Practice Address - Country:US
Practice Address - Phone:302-897-8496
Practice Address - Fax:484-489-2787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT0250882251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty