Healthcare Provider Details

I. General information

NPI: 1689363418
Provider Name (Legal Business Name): LEAH WOODS-BANNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2023
Last Update Date: 05/08/2023
Certification Date: 05/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 LONGVIEW CT
NORTHVALE NJ
07647-1317
US

IV. Provider business mailing address

406 LONGVIEW CT
NORTHVALE NJ
07647-1317
US

V. Phone/Fax

Practice location:
  • Phone: 201-577-4044
  • Fax:
Mailing address:
  • Phone: 201-577-4044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number489340
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: