Healthcare Provider Details

I. General information

NPI: 1215750054
Provider Name (Legal Business Name): DARRYL LOUIS LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2024
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 N OLDEN AVENUE EXT STE 29
EWING NJ
08618-2111
US

IV. Provider business mailing address

1901 N OLDEN AVENUE EXT STE 29
EWING NJ
08618-2111
US

V. Phone/Fax

Practice location:
  • Phone: 609-237-7100
  • Fax: 609-616-7904
Mailing address:
  • Phone: 609-237-7100
  • Fax: 609-616-7904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06246700
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: