Provider Demographics
NPI:1790406122
Name:LOFTUS, RAVEN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:LOFTUS
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:RAVEN
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:11 EAGLE ROCK AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:EAST HANOVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07936-3167
Mailing Address - Country:US
Mailing Address - Phone:973-887-9000
Mailing Address - Fax:973-887-3816
Practice Address - Street 1:63 LACEY RD STE H
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:NJ
Practice Address - Zip Code:08759-2966
Practice Address - Country:US
Practice Address - Phone:732-716-0111
Practice Address - Fax:732-716-0114
Is Sole Proprietor?:No
Enumeration Date:2022-09-05
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA02112800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist