Provider Demographics
NPI:1811265259
Name:WEGNER, KEVIN (OTR)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WEGNER
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 FEDERAL ST # 200
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1088
Mailing Address - Country:US
Mailing Address - Phone:856-356-4924
Mailing Address - Fax:
Practice Address - Street 1:3 COOPER PLZ
Practice Address - Street 2:SUITE 408
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1438
Practice Address - Country:US
Practice Address - Phone:856-325-6674
Practice Address - Fax:856-968-8288
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00334200225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR00334200OtherNJ LICENSE