Provider Demographics
NPI:1972928968
Name:WIRTH, LAUREN TRACEY (PTA)
Entity type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:TRACEY
Last Name:WIRTH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 WHITESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-5139
Mailing Address - Country:US
Mailing Address - Phone:732-912-6690
Mailing Address - Fax:
Practice Address - Street 1:288 WHITESVILLE RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-5139
Practice Address - Country:US
Practice Address - Phone:732-912-6690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-27
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00210900225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant