Healthcare Provider Details

I. General information

NPI: 1619676947
Provider Name (Legal Business Name): MARISSA MASTROCOLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2023
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NJ-34
MATAWAN NJ
07747
US

IV. Provider business mailing address

1000 NJ-34
MATAWAN NJ
07747
US

V. Phone/Fax

Practice location:
  • Phone: 732-520-2024
  • Fax:
Mailing address:
  • Phone: 732-520-2024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SC06678700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: