Healthcare Provider Details

I. General information

NPI: 1669267837
Provider Name (Legal Business Name): MARTHA HANNA LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 04/10/2025
Certification Date: 04/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BETHANY RD STE 92
HAZLET NJ
07730-1669
US

IV. Provider business mailing address

40 KENNEDY BLVD UNIT 304
BAYONNE NJ
07002-5314
US

V. Phone/Fax

Practice location:
  • Phone: 855-500-3848
  • Fax:
Mailing address:
  • Phone: 201-238-7908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37AC00834400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: