Provider Demographics
NPI:1194155796
Name:DEZENDORF, SANDRA
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:DEZENDORF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 RIEDER RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2805
Mailing Address - Country:US
Mailing Address - Phone:848-210-3946
Mailing Address - Fax:
Practice Address - Street 1:40 RIEDER RD
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-2805
Practice Address - Country:US
Practice Address - Phone:848-210-3946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV18KT00433700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist