Provider Demographics
NPI:1679354534
Name:LEQUEUX, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:LEQUEUX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 HUGO AVE
Mailing Address - Street 2:
Mailing Address - City:WOODLAND PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07424-3302
Mailing Address - Country:US
Mailing Address - Phone:973-934-1099
Mailing Address - Fax:
Practice Address - Street 1:19 HUGO AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND PARK
Practice Address - State:NJ
Practice Address - Zip Code:07424-3302
Practice Address - Country:US
Practice Address - Phone:973-934-1099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09238600224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty