Provider Demographics
NPI:1831876325
Name:FIREWORKER, RISA (OTR/L)
Entity type:Individual
Prefix:
First Name:RISA
Middle Name:
Last Name:FIREWORKER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 BUCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-2605
Mailing Address - Country:US
Mailing Address - Phone:845-825-4191
Mailing Address - Fax:
Practice Address - Street 1:12 BUCKINGHAM DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2605
Practice Address - Country:US
Practice Address - Phone:845-825-4191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01125000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist