Healthcare Provider Details

I. General information

NPI: 1437855152
Provider Name (Legal Business Name): SELF EMPLOYED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2023
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 FRANKLIN AVE STE 205
NUTLEY NJ
07110-1645
US

IV. Provider business mailing address

349 FRANKLIN AVE STE 205
NUTLEY NJ
07110-1645
US

V. Phone/Fax

Practice location:
  • Phone: 862-452-4883
  • Fax:
Mailing address:
  • Phone: 862-452-4883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MELISSA J MIDDLEMAN
Title or Position: MELISSA MIDDLEMAN, LCSW
Credential: LCSW
Phone: 862-452-4883