Provider Demographics
NPI:1356815005
Name:BLUMENFRUCHT, MICHELLE (OTR)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BLUMENFRUCHT
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 1:411 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-2819
Mailing Address - Country:US
Mailing Address - Phone:201-833-1968
Mailing Address - Fax:
Practice Address - Street 1:6612 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1719
Practice Address - Country:US
Practice Address - Phone:201-854-5511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00859900225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist