Provider Demographics
NPI:1952807141
Name:PRA, GWEN A (MHA, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:A
Last Name:PRA
Suffix:
Gender:F
Credentials:MHA, OTR/L
Other - Prefix:MRS
Other - First Name:GWEN
Other - Middle Name:A
Other - Last Name:KAULFERS-PRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:77 CHUCKANUTT DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07436-3728
Mailing Address - Country:US
Mailing Address - Phone:201-519-5251
Mailing Address - Fax:
Practice Address - Street 1:620 ROUTE 23
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-1468
Practice Address - Country:US
Practice Address - Phone:973-588-4486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR00068400225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ$$$$$$$$$OtherOCCUPATIONAL THERAPIST