Healthcare Provider Details

I. General information

NPI: 1720329576
Provider Name (Legal Business Name): JEDIEDJAH MOSHE RODRIGUES PEREIRA MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2013
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 TODD CT
LAKEWOOD NJ
08701-2256
US

IV. Provider business mailing address

1212 TODD CT
LAKEWOOD NJ
08701-2256
US

V. Phone/Fax

Practice location:
  • Phone: 732-814-4648
  • Fax:
Mailing address:
  • Phone: 732-814-4648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05605500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number37LC0021100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: