Healthcare Provider Details

I. General information

NPI: 1073586996
Provider Name (Legal Business Name): CHARLES ROLAND LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 BEAUVOIR AVE
SUMMIT NJ
07901-3533
US

IV. Provider business mailing address

PO BOX 23831
NEWARK NJ
07189-0001
US

V. Phone/Fax

Practice location:
  • Phone: 908-522-3586
  • Fax:
Mailing address:
  • Phone: 973-971-7184
  • Fax: 973-290-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SC01454500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: