Provider Demographics
NPI:1891235073
Name:TRACHTENBERG, MARK
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:TRACHTENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:689 WEST MAIN STEEET
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728
Mailing Address - Country:US
Mailing Address - Phone:732-414-0138
Mailing Address - Fax:
Practice Address - Street 1:689 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2511
Practice Address - Country:US
Practice Address - Phone:732-414-0139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09116400225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist