Healthcare Provider Details

I. General information

NPI: 1356440739
Provider Name (Legal Business Name): KENNETH RAYMOND MISCHNER M.S.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 STOCKTON ST
PRINCETON NJ
08540-6813
US

IV. Provider business mailing address

22 STOCKTON ST
PRINCETON NJ
08540-6813
US

V. Phone/Fax

Practice location:
  • Phone: 609-924-0060
  • Fax:
Mailing address:
  • Phone: 609-924-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number44SC04841600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: