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General NPI Number Information
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NPI Number | 1932217098
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Entity Type | Individual
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Provider Name | BIRGIT PETRA ICKENROTH A.T.C.
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Gender | Female
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Dates
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Enumeration Date | 08/29/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 700 N TUCKAHOE RD
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City | WILLIAMSTOWN
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State | NJ
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Zip | 08094-3512
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Country | US
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Telephone | 856-262-8200
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Fax |
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Provider Business Mailing Address
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Address Line | 339 LEGION CT # A
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City | PITMAN
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State | NJ
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Zip | 08071-2435
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Country | US
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Telephone | 856-582-9110
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 25MT00068800
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License Number State | NJ
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