Provider Demographics
NPI:1144358227
Name:FENNELLY, ANGELA MARIE (OTR)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:FENNELLY
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:241 KEARNY AVE
Mailing Address - Street 2:APT. 6
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-2525
Mailing Address - Country:US
Mailing Address - Phone:201-390-1536
Mailing Address - Fax:
Practice Address - Street 1:300 MARKET ST
Practice Address - Street 2:
Practice Address - City:SADDLE BROOK
Practice Address - State:NJ
Practice Address - Zip Code:07663-5309
Practice Address - Country:US
Practice Address - Phone:201-368-6117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00386200225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR00386200OtherOCCUPATIONAL THERAPIST