Healthcare Provider Details

I. General information

NPI: 1154530954
Provider Name (Legal Business Name): GREGG ALAN FRANK OTRL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 SUNSET STRIP
SUCCASUNNA NJ
07876-1345
US

IV. Provider business mailing address

5 TANGLEWOOD CT
RANDOLPH NJ
07869-4306
US

V. Phone/Fax

Practice location:
  • Phone: 973-252-9292
  • Fax: 973-252-9377
Mailing address:
  • Phone: 973-252-9292
  • Fax: 973-252-9377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberTR001815
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: