Provider Demographics
NPI:1427744663
Name:ROLDAN, JUSTIN (OTR/L)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ROLDAN
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:TUCKERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08087-0510
Mailing Address - Country:US
Mailing Address - Phone:609-296-0440
Mailing Address - Fax:609-812-5112
Practice Address - Street 1:7 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TUCKERTON
Practice Address - State:NJ
Practice Address - Zip Code:08087-2615
Practice Address - Country:US
Practice Address - Phone:609-296-0440
Practice Address - Fax:609-812-5112
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01120600225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist