Healthcare Provider Details

I. General information

NPI: 1760781884
Provider Name (Legal Business Name): COLEEN M O'CONNOR CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6-16 E BLACKWELL ST
DOVER NJ
07801-4664
US

IV. Provider business mailing address

10 BALCHEN WAY
ROCKAWAY NJ
07866-4702
US

V. Phone/Fax

Practice location:
  • Phone: 201-400-0219
  • Fax:
Mailing address:
  • Phone: 201-400-0219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number26BT00224700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: