Provider Demographics
NPI:1861046575
Name:KOSSIFOS, EMILY ROSE (DPT)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:KOSSIFOS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1014
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1014
Mailing Address - Country:US
Mailing Address - Phone:732-855-9751
Mailing Address - Fax:732-855-9751
Practice Address - Street 1:1180 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1311
Practice Address - Country:US
Practice Address - Phone:908-276-2626
Practice Address - Fax:908-276-8260
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-31
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01870200261QP2000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy