Provider Demographics
NPI:1801815378
Name:FORTUNA, ILA DORIS (OTR)
Entity Type:Individual
Prefix:
First Name:ILA
Middle Name:DORIS
Last Name:FORTUNA
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:ILA
Other - Middle Name:DORIS
Other - Last Name:WERNIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:776 SHREWSBURY AVE
Mailing Address - Street 2:# S101
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-3006
Mailing Address - Country:US
Mailing Address - Phone:631-451-3773
Mailing Address - Fax:631-451-3939
Practice Address - Street 1:776 SHREWSBURY AVE
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07724-3006
Practice Address - Country:US
Practice Address - Phone:732-741-0665
Practice Address - Fax:732-741-0668
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00096000225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ102330Medicare ID - Type Unspecified