Healthcare Provider Details

I. General information

NPI: 1952839268
Provider Name (Legal Business Name): KIMBERLY FAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W MAIN ST STE 2
FREEHOLD NJ
07728-2523
US

IV. Provider business mailing address

900 W MAIN ST STE 2
FREEHOLD NJ
07728-2523
US

V. Phone/Fax

Practice location:
  • Phone: 732-431-3602
  • Fax: 732-431-3603
Mailing address:
  • Phone: 732-431-3602
  • Fax: 732-431-3603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberTR00126500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: