Provider Demographics
NPI:1871069963
Name:SUDOL, MARK (OT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:SUDOL
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1194 WESTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:WEST MILFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07480-3008
Mailing Address - Country:US
Mailing Address - Phone:973-930-7377
Mailing Address - Fax:
Practice Address - Street 1:167 ROUTE 304
Practice Address - Street 2:
Practice Address - City:BARDONIA
Practice Address - State:NY
Practice Address - Zip Code:10954-2050
Practice Address - Country:US
Practice Address - Phone:973-930-7377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022873225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist