Healthcare Provider Details

I. General information

NPI: 1386470045
Provider Name (Legal Business Name): CHAYA E CARMEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 AVE OF THE STATES
LAKEWOOD NJ
08701-4789
US

IV. Provider business mailing address

5A OASIS CT
LAKEWOOD NJ
08701-2381
US

V. Phone/Fax

Practice location:
  • Phone: 732-961-7413
  • Fax:
Mailing address:
  • Phone: 973-930-9171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06820700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: