Healthcare Provider Details

I. General information

NPI: 1023330024
Provider Name (Legal Business Name): ALBA J VIZCAINO LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 LEE STREET RARITAN BAY MENTAL HEALTH CENTER
PERTH AMBOY NJ
08861-0353
US

IV. Provider business mailing address

570 LEE STREET RARITAN BAY MENTAL HEALTH CENTER
PERTH AMBOY NJ
08861-0353
US

V. Phone/Fax

Practice location:
  • Phone: 732-442-1666
  • Fax:
Mailing address:
  • Phone: 732-442-1666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SL05570600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: