Healthcare Provider Details

I. General information

NPI: 1104346717
Provider Name (Legal Business Name): THERESE M MIERSWA LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2017
Last Update Date: 06/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 HILLCREST RD
RIDGEWOOD NJ
07450-1520
US

IV. Provider business mailing address

439 HILLCREST RD
RIDGEWOOD NJ
07450-1520
US

V. Phone/Fax

Practice location:
  • Phone: 201-835-6485
  • Fax:
Mailing address:
  • Phone: 201-835-6485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL05903700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: