Provider Demographics
NPI:1912361551
Name:OCCUPATIONAL PEDIATRIC THERAPY SERVICES
Entity Type:Organization
Organization Name:OCCUPATIONAL PEDIATRIC THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KALYN
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKLINE
Authorized Official - Suffix:
Authorized Official - Credentials:OTMS
Authorized Official - Phone:860-417-8158
Mailing Address - Street 1:209 TEANECK ROAD
Mailing Address - Street 2:
Mailing Address - City:BARNEGAT
Mailing Address - State:NJ
Mailing Address - Zip Code:08005-2150
Mailing Address - Country:US
Mailing Address - Phone:860-417-8158
Mailing Address - Fax:
Practice Address - Street 1:600 GREGORY AVE
Practice Address - Street 2:
Practice Address - City:WEEHAWKEN
Practice Address - State:NJ
Practice Address - Zip Code:07086-5814
Practice Address - Country:US
Practice Address - Phone:860-417-8158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-10
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00625700225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty