Healthcare Provider Details

I. General information

NPI: 1073001830
Provider Name (Legal Business Name): KRISTA SANTOS, LCSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FRANKLIN AVE
NUTLEY NJ
07110-3202
US

IV. Provider business mailing address

38 LAKE SHORE DR
ROCKAWAY NJ
07866-1409
US

V. Phone/Fax

Practice location:
  • Phone: 973-667-6074
  • Fax:
Mailing address:
  • Phone: 908-425-0103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number44SC05759600
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MS. KRISTA D SANTOS
Title or Position: OWNER
Credential: LCSW
Phone: 908-425-0103