Provider Demographics
NPI:1700122330
Name:COUILLARD, CYNTHIA ANN
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ANN
Last Name:COUILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:ANN
Other - Last Name:CZOCHANSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:96 WOLFS CORNER RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07860-5432
Mailing Address - Country:US
Mailing Address - Phone:973-383-6104
Mailing Address - Fax:
Practice Address - Street 1:145 STATE PARK RD
Practice Address - Street 2:
Practice Address - City:BLAIRSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07825-4206
Practice Address - Country:US
Practice Address - Phone:908-459-4128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09089200224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant