Provider Demographics
NPI:1083820054
Name:ROTH, GREGORY RYAN (OTR, CHT)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:RYAN
Last Name:ROTH
Suffix:
Gender:M
Credentials:OTR, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WORLDS FAIR DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-1369
Mailing Address - Country:US
Mailing Address - Phone:732-537-0909
Mailing Address - Fax:732-564-9032
Practice Address - Street 1:2 WORLDS FAIR DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-1369
Practice Address - Country:US
Practice Address - Phone:732-537-0909
Practice Address - Fax:732-564-9032
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00127200225XH1200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR00127200OtherNJ LICENSE