Healthcare Provider Details

I. General information

NPI: 1700122330
Provider Name (Legal Business Name): CYNTHIA ANN COUILLARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CYNTHIA ANN CZOCHANSKI

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 12/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 STATE PARK RD
BLAIRSTOWN NJ
07825-4206
US

IV. Provider business mailing address

96 WOLFS CORNER RD
NEWTON NJ
07860-5432
US

V. Phone/Fax

Practice location:
  • Phone: 908-459-4128
  • Fax:
Mailing address:
  • Phone: 973-383-6104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number46TA09089200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: