Healthcare Provider Details

I. General information

NPI: 1396251393
Provider Name (Legal Business Name): CENTER PSYCHOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2017
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 MAIN ST
AVON BY THE SEA NJ
07717-1018
US

IV. Provider business mailing address

508 MAIN ST
AVON BY THE SEA NJ
07717-1018
US

V. Phone/Fax

Practice location:
  • Phone: 732-829-2141
  • Fax: 732-988-4317
Mailing address:
  • Phone: 732-829-2141
  • Fax: 732-988-4317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC04686900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number44SC04686900
License Number StateNJ

VIII. Authorized Official

Name: MS. MARGARET MARY CUNNIFF
Title or Position: OWNER
Credential: LCSW, LCADC
Phone: 732-829-2141