Provider Demographics
NPI:1609613264
Name:SERRITELLA, OLIVIA ROSE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:ROSE
Last Name:SERRITELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HAYNES CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9540
Mailing Address - Country:US
Mailing Address - Phone:973-986-4124
Mailing Address - Fax:
Practice Address - Street 1:751 ROUTE 73 N STE 1
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3456
Practice Address - Country:US
Practice Address - Phone:856-823-1793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTL-4504235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist