Healthcare Provider Details

I. General information

NPI: 1518434620
Provider Name (Legal Business Name): ICDL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 09/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 RIVERVIEW DR STE 201
TOTOWA NJ
07512-1165
US

IV. Provider business mailing address

999 RIVERVIEW DR STE 201
TOTOWA NJ
07512-1165
US

V. Phone/Fax

Practice location:
  • Phone: 973-797-9680
  • Fax:
Mailing address:
  • Phone: 973-797-9680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY GUENZEL
Title or Position: CEO
Credential:
Phone: 973-797-9680