Provider Demographics
NPI:1629198429
Name:BRUTHER, TRACEY MICHELLE (OTR)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:MICHELLE
Last Name:BRUTHER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1895 BREAKERS DR
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-4720
Mailing Address - Country:US
Mailing Address - Phone:609-698-3759
Mailing Address - Fax:
Practice Address - Street 1:685 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5228
Practice Address - Country:US
Practice Address - Phone:732-364-3772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00387000225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist