Healthcare Provider Details

I. General information

NPI: 1033320122
Provider Name (Legal Business Name): JACQUELINE SUZANNE STADLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 09/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 LEE STREET
PERTH AMBOY NJ
08861-3053
US

IV. Provider business mailing address

570 LEE STREET
PERTH AMBOY NJ
08861-3053
US

V. Phone/Fax

Practice location:
  • Phone: 732-442-1666
  • Fax: 732-442-9512
Mailing address:
  • Phone: 732-442-1666
  • Fax: 732-442-9512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC05320800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: