Provider Demographics
NPI:1053558171
Name:FAGERSTROM, JOANNE (PT)
Entity type:Individual
Prefix:MRS
First Name:JOANNE
Middle Name:
Last Name:FAGERSTROM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8200 FLOURTOWN AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:WYNDMOOR
Mailing Address - State:PA
Mailing Address - Zip Code:19038-7976
Mailing Address - Country:US
Mailing Address - Phone:215-233-5572
Mailing Address - Fax:215-233-5584
Practice Address - Street 1:8200 FLOURTOWN AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:WYNDMOOR
Practice Address - State:PA
Practice Address - Zip Code:19038-7976
Practice Address - Country:US
Practice Address - Phone:215-233-5572
Practice Address - Fax:215-233-5584
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT003491L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist