Provider Demographics
NPI:1669072849
Name:ROSALIE, JOHN NICHOLAS (OTR/L)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:NICHOLAS
Last Name:ROSALIE
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:579 CRANBURY RD STE C
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-5405
Practice Address - Country:US
Practice Address - Phone:732-432-0733
Practice Address - Fax:732-432-9131
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC017304225X00000X
NJ46TR00925500225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist