Provider Demographics
NPI:1215603519
Name:MORA, ROSANNA C
Entity Type:Individual
Prefix:
First Name:ROSANNA
Middle Name:C
Last Name:MORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:NJ
Mailing Address - Zip Code:07644-2109
Mailing Address - Country:US
Mailing Address - Phone:973-652-2736
Mailing Address - Fax:
Practice Address - Street 1:63 RICHMOND ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:NJ
Practice Address - Zip Code:07644-2109
Practice Address - Country:US
Practice Address - Phone:973-652-2736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010736224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant