Provider Demographics
NPI:1437179389
Name:HIDAYAT, ROSLIN (PT)
Entity type:Individual
Prefix:
First Name:ROSLIN
Middle Name:
Last Name:HIDAYAT
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 1:151 KNOLLCROFT RD BLD 19
Mailing Address - Street 2:APT 18
Mailing Address - City:LYONS
Mailing Address - State:NJ
Mailing Address - Zip Code:07939
Mailing Address - Country:US
Mailing Address - Phone:908-350-3064
Mailing Address - Fax:
Practice Address - Street 1:151 KNOLLCROFT RD BLD 19
Practice Address - Street 2:APT 18
Practice Address - City:LYONS
Practice Address - State:NJ
Practice Address - Zip Code:07939
Practice Address - Country:US
Practice Address - Phone:908-350-3064
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist