Healthcare Provider Details

I. General information

NPI: 1447504931
Provider Name (Legal Business Name): TASIA MILICEVIC LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2012
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 MAIN ST STE 1
HACKENSACK NJ
07601-4907
US

IV. Provider business mailing address

PO BOX 924
MAYWOOD NJ
07607-0924
US

V. Phone/Fax

Practice location:
  • Phone: 201-528-5757
  • Fax: 201-322-3738
Mailing address:
  • Phone: 201-528-5757
  • Fax: 201-322-3738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05834900
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: