Provider Demographics
NPI:1992084867
Name:ENCABO, MICHELLE GALLARDO BANSAGAN (PT)
Entity type:Individual
Prefix:
First Name:MICHELLE GALLARDO
Middle Name:BANSAGAN
Last Name:ENCABO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 POMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1813
Mailing Address - Country:US
Mailing Address - Phone:973-433-0732
Mailing Address - Fax:973-433-0733
Practice Address - Street 1:902 N 5TH ST
Practice Address - Street 2:UNIT C-103
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-4804
Practice Address - Country:US
Practice Address - Phone:973-732-4822
Practice Address - Fax:973-732-4821
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01340100225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist