# GLOUCESTER PHYSICAL THERAPY, PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1295837722
- **Authorized official:** DR. MAIKUTLO B KEBAETSE PHD, PT (PRESIDENT)
- **Authorized official phone:** (856) 224-0400

## Contact information

- **Practice address:** 541 MANTUA AVE, PAULSBORO, NJ 08066-1178
- **Practice address phone:** (856) 224-0400
- **Practice address fax:** (856) 224-0466
- **Mailing address:** PO BOX 277, PAULSBORO, NJ 08066-0277
- **Mailing address phone:** (856) 224-0400
- **Mailing address fax:** (856) 224-0466

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 225100000X | Physical Therapist | 40QA00685900 | NJ | Yes |

## Other

- **Enumeration date:** 09/04/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 2410631000 | AMERIHEALTH IND. ID \# | NJ |
| 01 | — | 2410669000 | AMERIHEALTH GROUP ID | NJ |