Healthcare Provider Details

I. General information

NPI: 1588114417
Provider Name (Legal Business Name): INTERNATIONAL CENTER FOR OPTIMAL LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2016
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 LASKO LN
PARLIN NJ
08859-2331
US

IV. Provider business mailing address

415 LASKO LN
PARLIN NJ
08859-2331
US

V. Phone/Fax

Practice location:
  • Phone: 201-779-1653
  • Fax:
Mailing address:
  • Phone: 201-779-1653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number44SC05646800
License Number StateNJ

VIII. Authorized Official

Name: MRS. DIONNE MARLENE FRANK
Title or Position: DIRECTOR
Credential: LCSW
Phone: 201-779-1653