Provider Demographics
NPI:1740307107
Name:KIRK, GINA (OTR, ATP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:KIRK
Suffix:
Gender:F
Credentials:OTR, ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 PARK ST
Mailing Address - Street 2:#2 FRONT BUILDING
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-5914
Mailing Address - Country:US
Mailing Address - Phone:973-783-0405
Mailing Address - Fax:
Practice Address - Street 1:1199 PLEASANT VALLEY WAY
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1424
Practice Address - Country:US
Practice Address - Phone:973-731-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00401600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist