Provider Demographics
NPI:1386389591
Name:PORTAL, HADASSA (COTA)
Entity type:Individual
Prefix:
First Name:HADASSA
Middle Name:
Last Name:PORTAL
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 SHAYAS RD BSMT
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5564
Mailing Address - Country:US
Mailing Address - Phone:518-542-0234
Mailing Address - Fax:
Practice Address - Street 1:1135 E VETERANS HWY STE 4
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-5090
Practice Address - Country:US
Practice Address - Phone:732-813-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TA09226700224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant