Provider Demographics
NPI:1871916130
Name:PRO STAFF DYNAMIC HAND THERAPY, INC.
Entity type:Organization
Organization Name:PRO STAFF DYNAMIC HAND THERAPY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:KOPIDLOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR/L, CHT
Authorized Official - Phone:973-766-3523
Mailing Address - Street 1:265 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2712
Mailing Address - Country:US
Mailing Address - Phone:973-680-8390
Mailing Address - Fax:973-680-8391
Practice Address - Street 1:49 CLAREMONT AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-4854
Practice Address - Country:US
Practice Address - Phone:973-680-8390
Practice Address - Fax:973-680-8391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00508400225XH1200X
261QP2000X, 261QR0404X, 332B00000X, 332BC3200X, 335E00000X, 335E00000X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHandGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac Facilities
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty