Provider Demographics
NPI:1922998657
Name:ROTH, KRYSTAL
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:
Other - Last Name:ATIEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16 BEEMAN PL
Mailing Address - Street 2:
Mailing Address - City:SUCCASUNNA
Mailing Address - State:NJ
Mailing Address - Zip Code:07876-1336
Mailing Address - Country:US
Mailing Address - Phone:973-796-7711
Mailing Address - Fax:
Practice Address - Street 1:45 S NEW YORK RD STE 217
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-3820
Practice Address - Country:US
Practice Address - Phone:609-770-4522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-04
Last Update Date:2025-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTE013381225200000X
PATE013381225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant