Provider Demographics
NPI:1063682904
Name:FAHRENFELD, MICHELE B (PTA)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:B
Last Name:FAHRENFELD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 319
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-0319
Mailing Address - Country:US
Mailing Address - Phone:973-256-0330
Mailing Address - Fax:973-812-0339
Practice Address - Street 1:194 2ND AVE
Practice Address - Street 2:
Practice Address - City:CEDAR GROVE
Practice Address - State:NJ
Practice Address - Zip Code:07009-1141
Practice Address - Country:US
Practice Address - Phone:973-256-0330
Practice Address - Fax:973-812-0339
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00109200225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant