Healthcare Provider Details

I. General information

NPI: 1053469056
Provider Name (Legal Business Name): CYNTHIA A. SERVELLO MA, OTR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 STATE HWY ROUTE 10 EAST
SUCCASUNNA NJ
07876
US

IV. Provider business mailing address

23 HIGH AVE
RANDOLPH NJ
07869-1014
US

V. Phone/Fax

Practice location:
  • Phone: 973-960-4001
  • Fax: 973-252-4503
Mailing address:
  • Phone: 973-366-5157
  • Fax: 973-252-4503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License NumberTR 00265
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: