Healthcare Provider Details

I. General information

NPI: 1790975308
Provider Name (Legal Business Name): LAUREN FENWICK PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N DEAN ST
ENGLEWOOD NJ
07631-2532
US

IV. Provider business mailing address

24 RENIE LN
BLAUVELT NY
10913-1217
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-5775
  • Fax: 201-894-1366
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA00946800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: