Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225XE0001X | Environmental Modification | 46TR00461900 | NJ |
Y | 225XG0600X | Occupational Therapist - Gerontology | 46TR00461900 | NJ |
NPI | 1891117719 |
---|---|
Provider Name | Emily Balog |
First Address | Voorhees, NJ 08043-9573 |
Second Address | Voorhees, NJ 08043-9573 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/01/2014 |
Last Update Date | 12/01/2014 |