Healthcare Provider Details

I. General information

NPI: 1104646132
Provider Name (Legal Business Name): LIAT RACHEL KAYE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 SPRINGFIELD AVE
SUMMIT NJ
07901-2601
US

IV. Provider business mailing address

482 SPRINGFIELD AVE
SUMMIT NJ
07901-2601
US

V. Phone/Fax

Practice location:
  • Phone: 908-273-5558
  • Fax:
Mailing address:
  • Phone: 908-273-5558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37AC00801400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: