Provider Demographics
NPI:1710563853
Name:CARDILLO, LACEY SANTA (OTR/L)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:SANTA
Last Name:CARDILLO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 PINE BANK RD
Mailing Address - Street 2:
Mailing Address - City:FLEMINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08822-7165
Mailing Address - Country:US
Mailing Address - Phone:908-625-6574
Mailing Address - Fax:
Practice Address - Street 1:108 PINE BANK RD
Practice Address - Street 2:
Practice Address - City:FLEMINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08822-7165
Practice Address - Country:US
Practice Address - Phone:908-625-6574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00942700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist