Healthcare Provider Details

I. General information

NPI: 1124640677
Provider Name (Legal Business Name): ELAINE PEGUERO LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELAINE PEGUERO

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 MAIN ST
HACKENSACK NJ
07601-4812
US

IV. Provider business mailing address

271 BOULEVARD
NEW MILFORD NJ
07646-1707
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-5161
  • Fax: 201-488-5162
Mailing address:
  • Phone: 201-560-6389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00314900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: