Provider Demographics
NPI:1700452455
Name:CORPUZ, NERISSA FE (COTA/L)
Entity Type:Individual
Prefix:MISS
First Name:NERISSA
Middle Name:FE
Last Name:CORPUZ
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 NOLTON ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-2332
Mailing Address - Country:US
Mailing Address - Phone:973-336-0540
Mailing Address - Fax:
Practice Address - Street 1:1155 PLEASANT VALLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1498
Practice Address - Country:US
Practice Address - Phone:973-731-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-02
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09204300225XP0019X, 224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ117957772Medicaid