Healthcare Provider Details

I. General information

NPI: 1538714563
Provider Name (Legal Business Name): LORRAINE HANSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 08/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 LAUREL AVE
KEANSBURG NJ
07734-1125
US

IV. Provider business mailing address

25 THOROUGHBRED FARE
TINTON FALLS NJ
07753-7524
US

V. Phone/Fax

Practice location:
  • Phone: 732-787-8100
  • Fax:
Mailing address:
  • Phone: 732-610-2544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00269000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: