Provider Demographics
NPI:1083216733
Name:REARDON, RENEE (PTA)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:REARDON
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 1:900 ROUTE 9 N STE 410
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1003
Mailing Address - Country:US
Mailing Address - Phone:201-801-7141
Mailing Address - Fax:
Practice Address - Street 1:2630 E CHESTNUT AVE STE C5
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08361-8400
Practice Address - Country:US
Practice Address - Phone:856-692-1483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00128800225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant