Healthcare Provider Details

I. General information

NPI: 1316592785
Provider Name (Legal Business Name): KAITLYN VICTORIA VACCARELLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2019
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 E GRANT ST
WOODSTOWN NJ
08098-1400
US

IV. Provider business mailing address

100 PRESIDENTIAL BLVD
BALA CYNWYD PA
19004-1108
US

V. Phone/Fax

Practice location:
  • Phone: 856-769-4564
  • Fax: 856-769-4637
Mailing address:
  • Phone: 610-688-0904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number40Q0194500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT027931
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: