Provider Demographics
NPI:1609300185
Name:ULLRICH, CASSANDRA
Entity Type:Individual
Prefix:MS
First Name:CASSANDRA
Middle Name:
Last Name:ULLRICH
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 1:401 ROUTE 73 N STE 320
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:741 S 2ND AVE STE B
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9542
Practice Address - Country:US
Practice Address - Phone:609-748-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-12
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB10818200208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program