Provider Demographics
NPI:1437360575
Name:FEDORUK, RANDAL STUART (OT)
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:STUART
Last Name:FEDORUK
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 MOOSE HILL RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-4337
Mailing Address - Country:US
Mailing Address - Phone:917-279-0906
Mailing Address - Fax:203-286-1688
Practice Address - Street 1:65 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-3001
Practice Address - Country:US
Practice Address - Phone:973-972-0186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTR4600247500225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics