Provider Demographics
NPI:1417478678
Name:WACHSSTOCK, BAILA
Entity Type:Individual
Prefix:
First Name:BAILA
Middle Name:
Last Name:WACHSSTOCK
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 1:1112 SOMERSET AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-2138
Mailing Address - Country:US
Mailing Address - Phone:732-228-3505
Mailing Address - Fax:
Practice Address - Street 1:2557 HOOPER AVE
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6238
Practice Address - Country:US
Practice Address - Phone:732-701-3711
Practice Address - Fax:732-701-3709
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
46TR00303225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist