MEDICARE: DAVID AICHROTH LCADC, LSW,

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	104100000X	Social Worker	44SL05429400	NJ
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	3LC00163100	NJ

General Provider Information

NPI Number	:	1205155637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID AICHROTH LCADC, LSW,

Provider Business Mailing Address
First Line	:	11 DUNDAR RD STE 105
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-3513
Country	:	US
Telephone Number	:	631-219-9503
Fax Number	:	908-822-0449

Provider Business Practice Location Address
First Line	:	11 DUNDAR RD STE 105
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-3513
Country	:	US
Telephone Number	:	631-219-9503
Fax Number	:	908-822-0449

Authorized Official
Title or Position	:	LICENSED CLINICAL ALCHOL AND DRUG C
Name	:	MR. DAVID ANDRE AICHROTH JR.
Credential	:	LCADC
Telephone Number	:	631-219-9503

Provider Enumeration Date	:	05/25/2010
Last Update Date	:	05/23/2016

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