Healthcare Provider Details

I. General information

NPI: 1245957315
Provider Name (Legal Business Name): TANISHA ESANNASON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 VALLEY RD STE 2636
CLIFTON NJ
07013-1319
US

IV. Provider business mailing address

PO BOX 200272
NEWARK NJ
07102-0305
US

V. Phone/Fax

Practice location:
  • Phone: 908-845-3506
  • Fax:
Mailing address:
  • Phone: 908-845-3506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37FA00026400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: