Provider Demographics
NPI:1760874564
Name:GERVASIO, LAUREN (MOTR/L)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:GERVASIO
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:POOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MOTR/L
Mailing Address - Street 1:324 WINDSOR CT
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-1844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 PHEASANT RUN STE 100
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1877
Practice Address - Country:US
Practice Address - Phone:215-579-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC013808225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist