Provider Demographics
NPI:1265959092
Name:WISEMAN, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:WISEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:FARRAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 WHITESANDS WAY
Mailing Address - Street 2:
Mailing Address - City:LITTLE SILVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07739-1240
Mailing Address - Country:US
Mailing Address - Phone:732-977-1217
Mailing Address - Fax:
Practice Address - Street 1:101 CRAWFORDS CORNER ROAD
Practice Address - Street 2:SUITE 1116D
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1977
Practice Address - Country:US
Practice Address - Phone:732-226-0018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
NJ40QA01749200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist