Healthcare Provider Details

I. General information

NPI: 1174656409
Provider Name (Legal Business Name): PAMELA J PATER-ENNIS LCSW,M.DIV., PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PAMELA P ENNIS LCSW, M.DIV, PHD

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 BROOKVIEW TER
BERGENFIELD NJ
07621-3100
US

IV. Provider business mailing address

114 BROOKVIEW TERRACE
BERGENFIELD NJ
07621-4504
US

V. Phone/Fax

Practice location:
  • Phone: 201-962-6443
  • Fax: 201-541-8100
Mailing address:
  • Phone: 201-962-6443
  • Fax: 201-541-8100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberR042224-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05339100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: