Provider Demographics
NPI:1043617699
Name:RUTHERFORD RENNER, LAURA M (OT)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:M
Last Name:RUTHERFORD RENNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 NEW JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-1612
Mailing Address - Country:US
Mailing Address - Phone:856-854-4405
Mailing Address - Fax:
Practice Address - Street 1:208 NEW JERSEY AVE
Practice Address - Street 2:
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108-1612
Practice Address - Country:US
Practice Address - Phone:856-854-4405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00123400225X00000X
PAOC003949L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist