Healthcare Provider Details

I. General information

NPI: 1649291154
Provider Name (Legal Business Name): CATHERINE DENISE COUTSOURIDIS MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 KNOLLCROFT RD
LYONS NJ
07939-5001
US

IV. Provider business mailing address

PO BOX 277
THREE BRIDGES NJ
08887-0277
US

V. Phone/Fax

Practice location:
  • Phone: 908-647-0180
  • Fax: 908-604-5226
Mailing address:
  • Phone: 908-788-5351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number000453
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: