Individual
BIRGIT PETRA ICKENROTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
A.T.C.
Contact information
Practice address
700 N TUCKAHOE RD, WILLIAMSTOWN, NJ 08094-3512
(856) 262-8200
Mailing address
339 LEGION CT # A, PITMAN, NJ 08071-2435
(856) 582-9110
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
25MT00068800
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PROVIDER CODE 22
PROVIDER CODE
NJ
Enumeration date
08/29/2006
Last updated
07/08/2007
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