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General NPI Number Information
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NPI Number | 1952807141
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Entity Type | Individual
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Provider Name | GWEN A PRA MHA, OTR/L
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Gender | Female
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Dates
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Enumeration Date | 04/05/2018
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Last Update Date | 06/20/2018
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Provider Practice Location Address
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Address Line | 620 ROUTE 23
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City | POMPTON PLAINS
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State | NJ
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Zip | 07444-1468
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Country | US
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Telephone | 973-588-4486
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Fax |
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Provider Business Mailing Address
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Address Line | 77 CHUCKANUTT DR
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City | OAKLAND
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State | NJ
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Zip | 07436-3728
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Country | US
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Telephone | 201-519-5251
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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 | 225XP0200X
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Taxonomy Name | Pediatric Occupational Therapist
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License Number | 46TR00068400
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License Number State | NJ
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