Healthcare Provider Details

I. General information

NPI: 1821426891
Provider Name (Legal Business Name): MINDY LIPPE LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 RIVER RD SUITE 9M
EDGEWATER NJ
07020-1456
US

IV. Provider business mailing address

7-08 FAIRHAVEN PL
FAIR LAWN NJ
07410-1626
US

V. Phone/Fax

Practice location:
  • Phone: 201-794-9797
  • Fax:
Mailing address:
  • Phone: 201-417-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL05919300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: