Provider Demographics
NPI:1003539131
Name:MULLIGAN, BRIELLE KAYLA (OTR)
Entity type:Individual
Prefix:
First Name:BRIELLE
Middle Name:KAYLA
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:OTR
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 508
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NJ
Mailing Address - Zip Code:08555-0508
Mailing Address - Country:US
Mailing Address - Phone:609-578-7403
Mailing Address - Fax:
Practice Address - Street 1:1405 ROUTE 18 STE 203
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-3777
Practice Address - Country:US
Practice Address - Phone:732-967-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ46TR01082800225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ46TR01082800OtherOT LICENSE