Healthcare Provider Details

I. General information

NPI: 1124665708
Provider Name (Legal Business Name): SUPPLANTER COUNSELING & MEDIATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2019
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 PARKWAY AVE STE 7
EWING NJ
08628-3006
US

IV. Provider business mailing address

1330 PARKWAY AVE STE 12
EWING NJ
08628-3006
US

V. Phone/Fax

Practice location:
  • Phone: 609-454-3080
  • Fax: 609-454-3078
Mailing address:
  • Phone: 609-454-3080
  • Fax: 609-454-3078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. JACQUELINE C PORTER- STEWART
Title or Position: OWNER
Credential: LCADC, LCSW, SAP
Phone: 609-454-3080