Healthcare Provider Details

I. General information

NPI: 1639499478
Provider Name (Legal Business Name): DANIELLE ALYSE VAZQUEZ OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DANIELLE ALYSE DEWHURST

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 NEW PROVIDENCE RD
MOUNTAINSIDE NJ
07092-2590
US

IV. Provider business mailing address

150 NEW PROVIDENCE RD
MOUNTAINSIDE NJ
07092
US

V. Phone/Fax

Practice location:
  • Phone: 908-233-9720
  • Fax: 908-301-5582
Mailing address:
  • Phone: 908-233-3720
  • Fax: 908-301-5582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number46TR00517100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: