Healthcare Provider Details

I. General information

NPI: 1194489161
Provider Name (Legal Business Name): TABULA RASA PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 10/26/2021
Certification Date: 10/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 WILEY AVE
PLAINFIELD NJ
07062-1343
US

IV. Provider business mailing address

190 WILEY AVE
PLAINFIELD NJ
07062-1343
US

V. Phone/Fax

Practice location:
  • Phone: 973-637-0375
  • Fax:
Mailing address:
  • Phone: 973-637-0375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER CHARICE SUMERLIN
Title or Position: LIC. MARRIAGE & FAMILY THERAPIST
Credential: PSYD, LMFT
Phone: 973-637-0375