Healthcare Provider Details

I. General information

NPI: 1225671613
Provider Name (Legal Business Name): KEVIN GERETY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

482 SPRINGFIELD AVE
SUMMIT NJ
07901-2601
US

IV. Provider business mailing address

112 BIRCH RD
FRANKLIN LAKES NJ
07417-2718
US

V. Phone/Fax

Practice location:
  • Phone: 908-273-5558
  • Fax:
Mailing address:
  • Phone: 201-783-6637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number44SL06503200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: