Healthcare Provider Details

I. General information

NPI: 1265664106
Provider Name (Legal Business Name): ALLA GOLBURT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33-11 BROADWAY
FAIR LAWN NJ
07410-4634
US

IV. Provider business mailing address

12 BREARLY CRES
FAIR LAWN NJ
07410-3553
US

V. Phone/Fax

Practice location:
  • Phone: 201-794-9797
  • Fax: 646-619-4299
Mailing address:
  • Phone: 201-791-3256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05366800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: