Healthcare Provider Details

I. General information

NPI: 1609380013
Provider Name (Legal Business Name): ESTHER LEGACY COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2017
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 CEDAR LN
TEANECK NJ
07666-4457
US

IV. Provider business mailing address

39 E 9TH ST
CLIFTON NJ
07011-1107
US

V. Phone/Fax

Practice location:
  • Phone: 201-429-5081
  • Fax:
Mailing address:
  • Phone: 201-562-8931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number44SC05657400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: YOHANNY C VALDERRAMA
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential:
Phone: 201-562-8931