Healthcare Provider Details

I. General information

NPI: 1124107479
Provider Name (Legal Business Name): GEORGE NICHOLAS VENEZIANO OTR L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GEORGE NICHOLAS VENEZIANO

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 FRANKLIN AVE
KEANSBURG NJ
07734-3145
US

IV. Provider business mailing address

103 FRANKLIN AVE
KEANSBURG NJ
07734-3145
US

V. Phone/Fax

Practice location:
  • Phone: 732-769-2447
  • Fax:
Mailing address:
  • Phone: 732-769-2447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0086791
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: