Provider Demographics
NPI:1871216614
Name:MANICKAM, PREMALATHA SR
Entity type:Individual
Prefix:
First Name:PREMALATHA
Middle Name:
Last Name:MANICKAM
Suffix:SR
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 US HIGHWAY 206 S SPC A114
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07930-2491
Mailing Address - Country:US
Mailing Address - Phone:908-888-0441
Mailing Address - Fax:732-289-3965
Practice Address - Street 1:270 US HIGHWAY 206 S SPC A114
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:NJ
Practice Address - Zip Code:07930-2491
Practice Address - Country:US
Practice Address - Phone:908-888-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02086700225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist