Healthcare Provider Details

I. General information

NPI: 1164357638
Provider Name (Legal Business Name): WAVE MAKERS PEDIATRIC THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 BLACK HORSE PIKE
MAYS LANDING NJ
08330-3111
US

IV. Provider business mailing address

12 HENRY RD
MARMORA NJ
08223-1573
US

V. Phone/Fax

Practice location:
  • Phone: 609-513-9381
  • Fax:
Mailing address:
  • Phone: 609-513-9381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. HEATHER M THERIAULT
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: MS,CCC-SLP/L
Phone: 609-513-9381