Provider Demographics
NPI:1376923664
Name:WATTLES, OLIVIA
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:WATTLES
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 1:329 E JIMMIE LEEDS RD
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-4110
Mailing Address - Country:US
Mailing Address - Phone:609-964-7901
Mailing Address - Fax:
Practice Address - Street 1:329 E JIMMIE LEEDS RD
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-4110
Practice Address - Country:US
Practice Address - Phone:609-964-7901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038851-1225100000X
NJ40A020182002251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist