Healthcare Provider Details

I. General information

NPI: 1225977812
Provider Name (Legal Business Name): RESILIENT ROOTS OT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2026
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 REMINGTON DR
EDISON NJ
08820-3635
US

IV. Provider business mailing address

550 COOKMAN AVE APT 225
ASBURY PARK NJ
07712-7182
US

V. Phone/Fax

Practice location:
  • Phone: 732-236-3485
  • Fax:
Mailing address:
  • Phone: 732-236-3485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MCKENNA MARY DICK
Title or Position: MEMBER/PART OWNER
Credential: OTR/L
Phone: 732-236-3485