Healthcare Provider Details

I. General information

NPI: 1538650569
Provider Name (Legal Business Name): VANESSA DE JESUS GUZMAN M.A., LAC, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 09/23/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 GRAND AVE STE 2H
RIDGEFIELD NJ
07657-1040
US

IV. Provider business mailing address

730 GRAND AVE STE 2H
RIDGEFIELD NJ
07657-1040
US

V. Phone/Fax

Practice location:
  • Phone: 201-430-5811
  • Fax:
Mailing address:
  • Phone: 201-430-5811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00725200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: