Healthcare Provider Details

I. General information

NPI: 1871967588
Provider Name (Legal Business Name): WARRIOR COGNITIVE AND PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 ATLANTIC AVE
NORTH WILDWOOD NJ
08260-5842
US

IV. Provider business mailing address

509 ATLANTIC AVE
NORTH WILDWOOD NJ
08260-5842
US

V. Phone/Fax

Practice location:
  • Phone: 215-694-0689
  • Fax: 215-632-7406
Mailing address:
  • Phone: 215-694-0689
  • Fax: 215-632-7406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC00526600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016960
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number46TR00237600
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41YS00331200
License Number StateNJ

VIII. Authorized Official

Name: MONICA LASALLE
Title or Position: PRESIDENT
Credential: MA, CCC/SLP
Phone: 215-694-0689