Healthcare Provider Details

I. General information

NPI: 1104715556
Provider Name (Legal Business Name): MANDALA INTEGRATIVE THERAPY AND PROFESSIONAL DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 05/09/2026
Certification Date: 05/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 MILLBURN AVE # 2009
SHORT HILLS NJ
07078-2508
US

IV. Provider business mailing address

514 MILLBURN AVE # 2009
SHORT HILLS NJ
07078-2508
US

V. Phone/Fax

Practice location:
  • Phone: 908-460-8003
  • Fax:
Mailing address:
  • Phone: 908-460-8003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE CROCKER
Title or Position: OWNER
Credential: LCSW
Phone: 908-460-8003