Healthcare Provider Details

I. General information

NPI: 1518373463
Provider Name (Legal Business Name): DERK MILES REPLOGLE LCADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 RINGWOOD AVE SUITE 301
HASKELL NJ
07420-1408
US

IV. Provider business mailing address

7 INDUSTRIAL RD
PEQUANNOCK NJ
07440-1901
US

V. Phone/Fax

Practice location:
  • Phone: 973-831-0613
  • Fax:
Mailing address:
  • Phone: 973-839-2520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number37LC00183300
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: