Provider Demographics
NPI:1003984451
Name:HEREDEA, GINA OTILIA (PT)
Entity Type:Individual
Prefix:MISS
First Name:GINA
Middle Name:OTILIA
Last Name:HEREDEA
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 1:6 HORIZON RD APT 512
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-6606
Mailing Address - Country:US
Mailing Address - Phone:551-221-0660
Mailing Address - Fax:201-224-3409
Practice Address - Street 1:6 HORIZON RD APT 512
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6606
Practice Address - Country:US
Practice Address - Phone:551-221-0660
Practice Address - Fax:201-224-3409
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01089000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ092597Medicare ID - Type UnspecifiedPHYSICAL THERAPY