Healthcare Provider Details

I. General information

NPI: 1760509830
Provider Name (Legal Business Name): SUPARNA SAMEER DESHMUKH OT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 CONNECTICUT DR STE 5
BURLINGTON NJ
08016-4177
US

IV. Provider business mailing address

4 HANLEY PARKE
MEDFORD NJ
08055-3364
US

V. Phone/Fax

Practice location:
  • Phone: 800-950-6066
  • Fax:
Mailing address:
  • Phone: 609-714-2115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00310900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: