Provider Demographics
NPI:1902269244
Name:AGOSTINI, MICHELLE VALERIE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:VALERIE
Last Name:AGOSTINI
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 HANCOCK AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-2160
Mailing Address - Country:US
Mailing Address - Phone:570-947-0400
Mailing Address - Fax:
Practice Address - Street 1:111 HANCOCK AVE APT 1
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-2160
Practice Address - Country:US
Practice Address - Phone:570-947-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01485400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist