Provider Demographics
NPI:1740810738
Name:BORGELLA, MAX
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:BORGELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-4553
Mailing Address - Country:US
Mailing Address - Phone:973-330-1431
Mailing Address - Fax:
Practice Address - Street 1:129 MITCHELL ST
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-4553
Practice Address - Country:US
Practice Address - Phone:973-330-1431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-19
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY403082224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty