Provider Demographics
NPI:1659549095
Name:LACIVITA, BURT MICHAEL (MS OTR)
Entity Type:Individual
Prefix:MR
First Name:BURT
Middle Name:MICHAEL
Last Name:LACIVITA
Suffix:
Gender:M
Credentials:MS OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 S CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2609
Mailing Address - Country:US
Mailing Address - Phone:201-923-7533
Mailing Address - Fax:
Practice Address - Street 1:81 NORTHFIELD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5342
Practice Address - Country:US
Practice Address - Phone:973-325-0229
Practice Address - Fax:973-325-1105
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00395600225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand