Healthcare Provider Details

I. General information

NPI: 1700572187
Provider Name (Legal Business Name): MVCG PSYCHOTHERAPY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 WARREN AVE OFC
SPRING LAKE NJ
07762-1233
US

IV. Provider business mailing address

512 WARREN AVE OFC
SPRING LAKE NJ
07762-1233
US

V. Phone/Fax

Practice location:
  • Phone: 732-575-0506
  • Fax:
Mailing address:
  • Phone: 732-575-0506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MANUELA VALVENTOS CORREIA-GUERRA
Title or Position: OWNER
Credential: MA, LPC, NCC
Phone: 732-575-0506