Healthcare Provider Details

I. General information

NPI: 1225376148
Provider Name (Legal Business Name): FREEDOM PEDIATRIC THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2013
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 2ND ST
LAKEWOOD NJ
08701-3351
US

IV. Provider business mailing address

310 2ND ST
LAKEWOOD NJ
08701-3351
US

V. Phone/Fax

Practice location:
  • Phone: 732-367-4569
  • Fax: 732-367-3253
Mailing address:
  • Phone: 732-367-4569
  • Fax: 732-367-3253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SHEVA S REISNER
Title or Position: ADMINISTRATOR
Credential:
Phone: 732-367-4569