Provider Demographics
NPI:1851092126
Name:BOLLERA, ATHENA POONACHA (BUSINESS OWNER)
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:POONACHA
Last Name:BOLLERA
Suffix:
Gender:F
Credentials:BUSINESS OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MORAINE RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3663
Mailing Address - Country:US
Mailing Address - Phone:732-877-4799
Mailing Address - Fax:
Practice Address - Street 1:21 MORAINE RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-3663
Practice Address - Country:US
Practice Address - Phone:732-877-4799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist