Healthcare Provider Details

I. General information

NPI: 1275840332
Provider Name (Legal Business Name): KITCHEN TABLE THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 NEWFIELD STREET
EAST ORANGE NJ
07017-5410
US

IV. Provider business mailing address

31 NEWFIELD STREET
EAST ORANGE NJ
07017-5410
US

V. Phone/Fax

Practice location:
  • Phone: 201-725-1807
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SC00586800
License Number StateNJ

VIII. Authorized Official

Name: CHARLENE W MASON-REESE
Title or Position: HEALTHCARE PROVIDER
Credential:
Phone: 201-725-1807