Healthcare Provider Details

I. General information

NPI: 1548352081
Provider Name (Legal Business Name): MARK JOSEPH DEMAREST LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 10/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 EISENHOWER PKWY SUITE 300
ROSELAND NJ
07068-1032
US

IV. Provider business mailing address

101 EISENHOWER PKWY SUITE 300
ROSELAND NJ
07068-1032
US

V. Phone/Fax

Practice location:
  • Phone: 973-986-3998
  • Fax:
Mailing address:
  • Phone: 973-986-3998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC00313600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: