Healthcare Provider Details

I. General information

NPI: 1346477528
Provider Name (Legal Business Name): KRYSTYNA TERESA VACCARELLI LCSW, LCADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 GRAND ST
JERSEY CITY NJ
07302-4238
US

IV. Provider business mailing address

250 LAUREL LN
CLARK NJ
07066-2732
US

V. Phone/Fax

Practice location:
  • Phone: 201-915-2883
  • Fax:
Mailing address:
  • Phone: 917-797-1536
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05386100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37LC00165300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: