Healthcare Provider Details

I. General information

NPI: 1568086403
Provider Name (Legal Business Name): KADIATU TARAWALIE MA,LPC,NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2020
Last Update Date: 06/06/2020
Certification Date: 06/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 PARKSIDE AVE APT 3G
EWING NJ
08638-2619
US

IV. Provider business mailing address

1501 PARKSIDE AVE APT 3G
EWING NJ
08638-2619
US

V. Phone/Fax

Practice location:
  • Phone: 609-248-0291
  • Fax:
Mailing address:
  • Phone: 609-248-0291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00675800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: