Provider Demographics
NPI:1508649807
Name:WITTSTOCK, TAYLOR MICHELLE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:MICHELLE
Last Name:WITTSTOCK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 ROUTE 70 STE 19
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 N ROUTE 73 UNIT 80
Practice Address - Street 2:
Practice Address - City:WEST BERLIN
Practice Address - State:NJ
Practice Address - Zip Code:08091-9202
Practice Address - Country:US
Practice Address - Phone:856-335-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02191300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist