Provider Demographics
NPI:1962282186
Name:NORVILLE, MARK RORY
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RORY
Last Name:NORVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:468 MORRIS AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-7504
Mailing Address - Country:US
Mailing Address - Phone:856-503-8825
Mailing Address - Fax:
Practice Address - Street 1:125 WASHINGTON VALLEY RD STE 3
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:NJ
Practice Address - Zip Code:07059-7179
Practice Address - Country:US
Practice Address - Phone:908-741-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00410300225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty