Healthcare Provider Details

I. General information

NPI: 1043498736
Provider Name (Legal Business Name): AJA REDMOND LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date: 01/24/2022
Reactivation Date: 08/25/2022

III. Provider practice location address

777 BLOOMFIELD AVE
CLIFTON NJ
07012-1242
US

IV. Provider business mailing address

PO BOX 702
SALEM NJ
08079-0702
US

V. Phone/Fax

Practice location:
  • Phone: 973-594-0125
  • Fax: 973-594-0536
Mailing address:
  • Phone: 856-571-7122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00322100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: