Provider Demographics
NPI:1932217098
Name:ICKENROTH, BIRGIT PETRA (ATC)
Entity Type:Individual
Prefix:
First Name:BIRGIT
Middle Name:PETRA
Last Name:ICKENROTH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 LEGION CT # A
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071-2435
Mailing Address - Country:US
Mailing Address - Phone:856-582-9110
Mailing Address - Fax:
Practice Address - Street 1:700 N TUCKAHOE RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08094-3512
Practice Address - Country:US
Practice Address - Phone:856-262-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT000688002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPROVIDER CODE 22OtherPROVIDER CODE