MEDICARE: MIGNOLIA PLACENCIA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	37AC00473300	NJ

General Provider Information

NPI Number	:	1124616446
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIGNOLIA PLACENCIA

Provider Business Mailing Address
First Line	:	113 KNOLLS RD
Second Line	:
City	:	BLOOMINGDALE
State	:	NJ
Zip	:	07403-1513
Country	:	US
Telephone Number	:	862-668-1348
Fax Number	:

Provider Business Practice Location Address
First Line	:	1401 VALLEY RD
Second Line	:
City	:	WAYNE
State	:	NJ
Zip	:	07470-2073
Country	:	US
Telephone Number	:	973-368-7781
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/03/2021
Last Update Date	:	01/03/2021

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Directions to “ MIGNOLIA PLACENCIA ” Practice Location

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