Healthcare Provider Details

I. General information

NPI: 1346676384
Provider Name (Legal Business Name): CAROLYN ROSE DEGORIA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROLYN ROSE KIRKUP DPT

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 09/30/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 CENTRAL AVE
NEW PROVIDENCE NJ
07974
US

IV. Provider business mailing address

416 COLONIAL AVE
WESTFIELD NJ
07090
US

V. Phone/Fax

Practice location:
  • Phone: 908-522-2215
  • Fax:
Mailing address:
  • Phone: 609-947-9588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40QA01908900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: