Healthcare Provider Details

I. General information

NPI: 1245453026
Provider Name (Legal Business Name): DOREEN MARIE PONTIUS-MOLOS L.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PARK AVE
DUMONT NJ
07628-3004
US

IV. Provider business mailing address

841 PALMER AVE
MAYWOOD NJ
07607-1719
US

V. Phone/Fax

Practice location:
  • Phone: 201-385-4400
  • Fax: 201-385-9689
Mailing address:
  • Phone: 201-556-1752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05534700
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: