Provider Demographics
NPI:1831791706
Name:GONG, RANDALL SCOTT (COTA/L)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:SCOTT
Last Name:GONG
Suffix:
Gender:M
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 1:737 WHALERS COVE PL
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-3018
Mailing Address - Country:US
Mailing Address - Phone:609-335-2033
Mailing Address - Fax:
Practice Address - Street 1:737 WHALERS COVE PL
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-3018
Practice Address - Country:US
Practice Address - Phone:609-335-2033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46T09167100224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant