Healthcare Provider Details

I. General information

NPI: 1679334981
Provider Name (Legal Business Name): JOANNE H O'DELL LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOANNE H KIM

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 04/21/2025
Certification Date: 04/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 N STATE RT 17 STE 100
PARAMUS NJ
07652-2648
US

IV. Provider business mailing address

402 AURORA AVE.
CLIFFSIDE PARK NJ
07010
US

V. Phone/Fax

Practice location:
  • Phone: 551-368-0304
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37AC00850600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: